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
The nurse recognizes that the patient is experiencing which transfusion complication?
a. Anaphylactic shock
b. Septicemia
c. Fluid volume overload
d. Hemolytic reaction
ANS: C
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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An ultrasound confirms that a 16-year-old girl is pregnant. How does the need for prenatal care and counseling for adolescents different from other age populations?
a. A pregnant adolescent is experiencing two major life transitions at the same time. b. Adolescents who get pregnant are more likely to have other chronic health problems. c. Adolescents are at greater risk for multifetal pregnancies. d. At this age, a pregnant adolescent will accept the nurse's advice.
The patient who has had an incarcerated hernia for many years begins to experience abdominal pain and vomit dark material with a fecal odor. The nurse recognizes these signs as indications of:
a. intestinal obstruction. b. ruptured bowel. c. gastroenteritis. d. duodenal ulcer.
A patient undergoing diagnostic tests says, "Nothing is wrong with me except a stubborn chest cold." The spouse reports the patient smokes, coughs daily, lost 15 pounds, and is easily fatigued. Which defense mechanism is the patient using?
a. Displacement b. Regression c. Projection d. Denial
Which of the following best reflects nursing's view of clients as holistic beings?
A) Physical, psychosocial, religious B) Mind, body, spirit C) Id, ego, superego D) Spiritual, egocentric, naive