A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic
The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions?
a. Fluid volume overload
b. Hemolytic reaction
c. Anaphylactic shock
d. Septicemia
ANS: A
The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic reaction would consist of flank pain, chills, and fever.
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A patient has been taking 10 aspirin tablets a day for his arthritis. He comes into the clinic complaining of a ringing in his ears. The nurse, after assessing the patient, tells him:
1. the tinnitus should improve over time. 2. he needs an injection of vitamin K. 3. to stop taking the aspirin and contact his physician for a different prescription. 4. to increase his fluid intake to 3000 mL a day.
The nurse in the hospital nursery understands the importance of maintaining body temperature in the neonate. Thermoregulation is difficult because:
a. A newborn cannot produce or conserve heat b. New mothers wrap their babies in blankets c. The neonate produces too much heat d. The baby is placed uncovered under the radiant heat
The community health nurse is reviewing with you perspectives on family. Using your knowledge that one way to learn about families is to assess them from a broad perspective, what is the grand nursing theory in nursing practice?
A) Present a systematic view of related statements to describe, explain, predict, or prescribe a phenomenon of interest B) Relates human experience to nursing practice and nursing care C) Assesses health patterns in 11 areas of family health D) Engages the family as a way to identify its strengths with attention to family dynamics and concerns related to health and illness
A respiratory rate greater than 25 per minute is____________________.
Fill in the blank(s) with the appropriate word(s).