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 B
Explanation
A. Diarrhea is not a typical finding associated with anemia from blood loss; it may occur for other reasons but is not directly related to low hemoglobin levels.
B. Fatigue is a common symptom in clients with anemia, particularly when hemoglobin levels are low, as there is reduced oxygen delivery to tissues, leading to feelings of weakness and tiredness.
C. Hypertension is unlikely to be present in a client with significant blood loss; instead, hypotension may be more expected due to reduced blood volume.
D. Bradycardia is not typically associated with anemia; in fact, tachycardia (increased heart rate) is more common as the body tries to compensate for reduced oxygen-carrying capacity.