A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
Distended jugular veins.
Generalized urticaria.
Bilateral flank pain.
Blood pressure 184/92 mm Hg.
The Correct Answer is B
A. Distended jugular veins may indicate fluid overload or congestive heart failure, not an allergic reaction.
B. Generalized urticaria, or hives, is a classic sign of an allergic transfusion reaction, presenting as an itchy rash or welts on the skin.
C. Bilateral flank pain is more indicative of a hemolytic reaction, particularly due to kidney involvement, rather than an allergic reaction.
D. A blood pressure of 184/92 mm Hg may suggest hypertension or a reaction, but it is not specific to allergic transfusion reactions, which are characterized by skin symptoms like urticaria.
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Correct Answer is B
Explanation
A. Increasing the consumption of protein-rich foods like baked salmon is beneficial for clients with AIDS, as they often require higher protein intake to support their immune system and overall health.
B. Eating raw fruits and vegetables can pose a risk for clients with compromised immune systems, as these foods may harbor pathogens that can lead to infections. This statement indicates a need for further education regarding safe food handling and preparation.
C. Washing plates and utensils with soap and hot water is a proper practice to maintain hygiene and prevent infections, especially for clients with weakened immune systems.
D. Asking a partner to clean the cat's litter box is a good precaution since cat litter can be a source of toxoplasmosis, which can be harmful to immunocompromised individuals.
Correct Answer is A
Explanation
A. This statement accurately reflects the importance of adherence to ART; if medication is missed, the virus may replicate unchecked, leading to drug resistance, which is a significant concern in HIV treatment.
B. This statement is incorrect because the conversion of RNA to DNA is a normal part of the HIV life cycle and is not directly prevented by taking medication on time.
C. While protease inhibitors do help prevent the assembly of new virions, the primary concern when missing doses is the risk of resistance rather than assembly prevention.
D. This statement is misleading; while effective ART can lead to an increase in CD4 counts over time, missing doses would not directly cause an increase in CD4 lymphocyte counts.