A nurse is preparing to transfuse one unit of packed RBC to a client who experienced a mild allergic reaction during a previous transfusion. The nurse should administer diphenhydramine prior to the transfusion for which of the following allergic responses?
Fluid overload
Urticaria
Hemolysis
Fever
The Correct Answer is B
A. Fluid overload is not an allergic reaction but rather a complication of transfusion related to the volume of fluid administered, thus diphenhydramine would not be appropriate.
B. Urticaria, or hives, is a common mild allergic reaction that can occur during blood transfusions. Administering diphenhydramine can help prevent or treat this response.
C. Hemolysis is a serious reaction involving the destruction of red blood cells, often due to blood type incompatibility; it is not alleviated by antihistamines.
D. Fever can occur during transfusions but is typically due to non-specific immune reactions and does not respond to diphenhydramine.
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Correct Answer is B
Explanation
A. Gingivitis is a form of gum disease that can occur in anyone, but it is not specifically related to low CD4-T-cell counts associated with AIDS.
B. Candidiasis, also known as oral thrush, is a fungal infection caused by Candida species. Clients with a significantly decreased CD4-T-cell count are at high risk for opportunistic infections, including candidiasis, due to their compromised immune systems.
C. Xerostomia refers to dry mouth, which can occur for various reasons but is not specifically an infectious condition linked to low CD4 counts.
D. Halitosis, or bad breath, can result from several factors, including poor oral hygiene or underlying health issues, but is not specifically linked to the immune status of a client with AIDS.
Correct Answer is C
Explanation
A. While knowing the location of the assault may be relevant for police reports, it does not directly pertain to the client’s health and potential exposure to HIV.
B. Permission to contact the police is important for legal reasons, but the priority is to address the client's health needs first.
C. Identifying the individual who assaulted the client is critical for assessing the risk of HIV exposure and determining the need for post-exposure prophylaxis (PEP). This question directly impacts the client’s immediate health care.
D. Understanding the day and time of the assault is useful for legal documentation but is less critical than assessing potential exposure to HIV.