A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should the nurse identify as an indication of a hemolytic transfusion reaction?

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Question 1 of 5

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings should the nurse identify as an indication of a hemolytic transfusion reaction?

Correct Answer: A

Rationale: The correct answer is A: Low back pain. Low back pain is a common sign of a hemolytic transfusion reaction, indicating the destruction of red blood cells. This finding requires immediate intervention as it can lead to serious complications such as renal failure. Bradycardia (choice B) is not typically associated with a hemolytic transfusion reaction. Chills (choice C) can be seen in febrile non-hemolytic transfusion reactions. Distended neck veins (choice D) are more indicative of fluid overload rather than a hemolytic reaction.

Question 2 of 5

A nurse is caring for a client who has a new prescription for enalapril. Which of the following findings should the nurse identify as an adverse effect of the medication?

Correct Answer: A

Rationale: Corrected Rationale: A persistent cough is a known adverse effect of enalapril, an ACE inhibitor. Enalapril can cause the accumulation of bradykinin, leading to a dry, persistent cough in some patients. Dry mouth (choice B) and urinary retention (choice C) are not typically associated with enalapril use. Insomnia (choice D) is also not a common adverse effect of enalapril. Therefore, the correct answer is A.

Question 3 of 5

A nurse is assessing a client who has a peripherally inserted central catheter (PICC). Which of the following findings should the nurse report to the provider?

Correct Answer: B

Rationale: Swelling of the arm above the insertion site is concerning as it can indicate complications like thrombosis, which require immediate attention. Redness at the insertion site is common and expected in the initial stages. A bruised area around the insertion site may result from the insertion procedure and is usually not alarming unless it worsens or becomes larger. A temperature of 37.2°C (99°F) is within the normal range and is not directly related to PICC complications.

Question 4 of 5

A client has a new prescription for alendronate. Which of the following instructions should the nurse include?

Correct Answer: C

Rationale: The correct instruction when taking alendronate is to remain upright for 30 minutes after administration. This helps prevent esophageal irritation, a known side effect of the medication. Option A is incorrect because alendronate should be taken in the morning on an empty stomach. Option B is incorrect as taking alendronate with food decreases its absorption. Option D is incorrect as alendronate should be swallowed whole with a full glass of water and not chewed.

Question 5 of 5

A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

Correct Answer: B

Rationale: A weight loss of 0.5 kg (1.1 lb) in 24 hours may indicate dehydration or malnutrition, which are critical concerns for a client receiving total parenteral nutrition (TPN). Therefore, the nurse should report this finding to the provider. Elevated blood glucose levels (Choice A) can be managed by adjusting TPN components, WBC count (Choice C) and a slightly elevated temperature (Choice D) are not directly related to TPN administration and may not require immediate intervention.

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