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 symptoms described in the scenario, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, are indicative of an immediate hypersensitivity reaction, also known as a Type I hypersensitivity reaction. This type of reaction is triggered by the release of histamine and other inflammatory mediators from mast cells and basophils. Symptoms can range from mild to severe and can manifest rapidly after exposure to the allergen, in this case, the blood transfusion. Common manifestations include skin reactions (e.g., itching, urticaria), respiratory symptoms (e.g., chest pain, wheezing), cardiovascular changes (e.g., tachycardia, hypotension), and gastrointestinal symptoms (e.g., nausea, vomiting).

Correct Answer: B

Rationale: The client's symptoms of abdominal pain, fever, and "horse barn" smelling diarrhea are concerning for Clostridium difficile infection, especially in the setting of receiving chemotherapy which can weaken the immune system. Clostridium difficile is a bacteria that can cause severe diarrhea and inflammation of the colon. Testing for Clostridium difficile in the stool is crucial for diagnosing the infection and guiding appropriate treatment. Therefore, advising the physician to order a stool test for Clostridium difficile would be the most important in this scenario to confirm the diagnosis and initiate appropriate management.

Correct Answer: B

Rationale: The greatest likelihood of an acute hemolytic reaction occurs when there is mismatch in the ABO blood group system, specifically when the recipient's plasma contains antibodies against the donor's red blood cells. In this scenario, giving O-positive blood to an A-positive client presents the highest risk because the A-positive client has anti-B antibodies in their plasma, which can attack the B antigens present on the O-positive donor red blood cells. This mismatch can lead to rapid destruction of the transfused red blood cells, causing an acute hemolytic reaction. It is crucial to ensure ABO compatibility to prevent such life-threatening reactions during blood product transfusions.

Correct Answer: B

Rationale: When taking the blood pressure of a client with AIDS, it is important for the nurse to use barrier techniques to prevent the potential transmission of infection. This includes wearing gloves to protect against exposure to blood or other bodily fluids, using disposable blood pressure cuffs and stethoscopes, and ensuring proper hand hygiene before and after the procedure. Barrier techniques help minimize the risk of cross-contamination and protect both the healthcare provider and the client from potential infections.

Correct Answer: A

Rationale: Monitoring intake and output of fluids is essential for an elderly client who develops severe bone marrow depression from chemotherapy for prostate cancer. Bone marrow depression can result in decreased production of blood cells, including red blood cells, white blood cells, and platelets. Monitoring intake and output of fluids helps assess hydration status and kidney function. Decreased fluid intake or output may indicate kidney damage or dehydration, which are common concerns in clients with bone marrow depression. Therefore, it is crucial for the nurse to monitor the client's fluid balance closely to ensure optimal functioning of the kidneys and prevent complications related to bone marrow suppression.