When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea and itching. When urticarial, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?

Correct Answer: A

Rationale: The correct answer is A: Type I (immediate, anaphylactic) hypersensitivity reaction. In this scenario, the client experiences symptoms shortly after the transfusion starts, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, which are indicative of an immediate hypersensitivity reaction. Type I reactions involve the release of histamine and other inflammatory mediators from mast cells and basophils, leading to the symptoms described. The nurse's prompt action of stopping the transfusion and notifying the physician aligns with managing this type of reaction. Incorrect choices: B: Type II (cytolytic, cytotoxic) hypersensitivity reaction - This type of reaction involves antibodies targeting specific cells, leading to their destruction. The symptoms described in the scenario are not consistent with this type of reaction. C: Type III (immune complex) hypersensitivity reaction - This type of reaction involves the formation of immune complexes that deposit in tissues, causing

Correct Answer: D

Rationale: The correct answer is D because educating the client about the disease process and its limitations is crucial in managing Chronic Fatigue Syndrome (CFS). By understanding the disease, the client can make informed decisions regarding their lifestyle, activities, and self-care. This empowers the client to manage symptoms effectively and prevent exacerbations. Choice A is not the most important factor as simply avoiding aggravating the disease does not address the overall management of CFS. Choice B focuses solely on drug therapy, which is only one aspect of the client's management and may not provide significant improvement for all clients with CFS. Choice C, altering diet and environment, can be helpful but may not be the most important factor as understanding the disease process and limitations is essential for long-term management and quality of life.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates an understanding of the key factors in managing hyperosmolar hyperglycemic nonketotic syndrome (HHNS), which include avoiding dehydration and being aware of changes in urination, thirst, and hunger. This statement shows awareness of the importance of maintaining hydration and recognizing early signs of worsening symptoms. Choice B is incorrect as consuming sugary soda can exacerbate the condition by further increasing blood sugar levels. Choice C is incorrect because while monitoring blood glucose levels is important, it is not the primary method of preventing HHNS. Choice D is incorrect because consuming high-carbohydrate snacks can contribute to elevated blood glucose levels, which is counterproductive in managing HHNS.

Correct Answer: B

Rationale: The correct answer is B: Fluid retention and weight gain. Prednisone is a corticosteroid that can cause fluid retention and weight gain as common adverse reactions. Here's the rationale: Prednisone is known to increase sodium and water retention in the body, leading to fluid retention and subsequent weight gain. This occurs due to the drug's impact on the body's electrolyte balance. Tetany and tremors (Choice A) are not common adverse reactions associated with prednisone use. Anorexia and weight loss (Choice C) are also not typical reactions, as prednisone is more likely to cause weight gain. Choice D, "None of the above," is incorrect as prednisone commonly causes fluid retention and weight gain as adverse reactions.

Correct Answer: C

Rationale: The correct answer is C because performing chest physiotherapy (CPT) at least two hours after meals helps prevent aspiration during the procedure. This timing reduces the risk of vomiting or regurgitation of food during CPT, which could lead to aspiration pneumonia. Slapping the chest wall gently (A) may not effectively clear secretions. Using vibration techniques (B) is not typically recommended for routine CPT. Planning apical drainage at the beginning of the session (D) is not necessary as it is not a standard practice for CPT.

Correct Answer: B

Rationale: The correct answer is B: Redness of the upper part of the feet. During lymphangiography, a contrast dye is injected into the lymphatic vessels. This may cause temporary redness in the upper part of the feet due to the dye spreading throughout the lymphatic system. Purplish stools (A), bluish urine (C), and coldness of the soles (D) are not expected side effects of lymphangiography and do not have a direct correlation with the procedure.

Correct Answer: A

Rationale: The correct answer is A because clients with Parkinson's, Huntington's diseases, or epilepsy often experience emotional challenges such as depression and anxiety due to the impact of their conditions on their daily lives. Emotional counseling helps address these issues. Additionally, these clients may struggle with basic self-care activities due to motor and cognitive deficits, making it crucial for nurses to assist them in performing daily tasks. Choice B is incorrect as clients with these conditions may experience paralysis or motor impairments, but it is not a universal symptom. Choice C is incorrect because the question does not mention bone issues in Parkinson's, Huntington's diseases, or epilepsy. Choice D is incorrect as aggression and violence are not common symptoms in clients with these neurologic deficits.

Correct Answer: C

Rationale: The correct answer is C: Obesity. Obesity is a known risk factor for colon cancer as it can lead to chronic inflammation and changes in hormone levels, increasing the risk of developing cancerous cells in the colon. Smoking (choice A) is more strongly associated with lung cancer. Heavy alcohol consumption (choice B) is linked to increased risk of liver and esophageal cancer, not colon cancer. Saccharin consumption (choice D) has not been definitively linked to colon cancer. In summary, obesity is the most relevant risk factor for colon cancer among the choices provided.

Correct Answer: B

Rationale: The correct answer is B because using a PICOT question involves formulating a research question to guide evidence-based practice. B indicates the nurse is implementing interventions based on scientific research, aligning with the PICOT framework (Patient, Intervention, Comparison, Outcome, Timeframe). This approach ensures that care decisions are supported by the best available evidence, leading to improved patient outcomes. Choice A is incorrect because practicing nursing based on court evidence does not align with the PICOT framework. Choice C is incorrect as using standardized care plans for all patients may not consider individual patient needs and preferences as required in a PICOT question. Choice D is incorrect as planning care based on tradition does not involve integrating current research evidence as in the PICOT approach.