The nurse is monitoring vital signs on a client receiving a blood ...

[sabina]

The nurse is monitoring vital signs on a client receiving a blood transfusion. If a transfusion febrile reaction occurs, the client experiences chills and fever, usually within:
 
  1. 3 hours.
  2. 2 hours.
  3. 60 minutes.
  4. 15 minutes.

Question 2

The nurse assesses crackles in the lungs of a client who is receiving IV therapy for shock. What should the nurse recognize that this finding indicates?
 
  1. Hypostatic pneumonia
  2. Hypovolemia
  3. Renal failure
  4. Hypervolemia

[kkenney]

Answer to Question 1

Answer: 4

1. In a febrile transfusion reaction, the client's antibodies react to the donor's white blood cells, causing fever and chills, usually within 15 minutes.
2. In a febrile transfusion reaction, the client's antibodies react to the donor's white blood cells, causing fever and chills, usually within 15 minutes.
3. In a febrile transfusion reaction, the client's antibodies react to the donor's white blood cells, causing fever and chills, usually within 15 minutes.
4. In a febrile transfusion reaction, the client's antibodies react to the donor's white blood cells, causing fever and chills, usually within 15 minutes.

Answer to Question 2

Answer: 4

1. Pneumonia is not likely to have developed in the client.
2. The client is receiving intravenous therapy for shock. Hypovolemia is likely to be resolving.
3. Crackles in the lungs are not a manifestation of renal failure.
4. Crackles reflect a shift of excess fluid from the vascular space to interstitial spaces in the lung, indicating that the client is receiving an excess of IV fluids.