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 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.
Correct Answer is C
Explanation
A. Decreasing intake of foods high in fiber is not necessary; in fact, fiber can help prevent constipation, a common side effect of iron supplements.
B. Vitamin C actually enhances the absorption of iron; thus, avoiding it is incorrect. Clients should be encouraged to consume vitamin C alongside their iron supplements to improve absorption.
C. Stools becoming darker in color is a common and expected side effect of ferrous sulfate due to the presence of unabsorbed iron. It is important for clients to know this to avoid unnecessary alarm.
D. Taking the medication on a full stomach may decrease absorption; it is generally recommended to take iron supplements on an empty stomach for optimal absorption unless gastrointestinal upset occurs.