Author Question: An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed ... (Read 167 times)

dakota nelson · **on:** Jun 28, 2018

An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These manifestations are most suggestive of:

a. Air embolism. c. Hemolytic reaction.
b. Allergic reaction. d. Circulatory overload.

Question 2

The nurse is planning care for an adolescent with acquired immunodeficiency syndrome. The priority nursing goal is to:

a. Prevent infection. c. Restore immunologic defenses.
b. Prevent secondary cancers. d. Identify source of infection.

cam1229 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: D
The signs of circulatory overload include distended neck veins, hypertension, crackles, dry cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Allergic reactions are manifested by urticaria, pruritus, flushing, asthmatic wheezing, and laryngeal edema. Hemolytic reactions are characterized by chills, shaking, fever, pain at infusion site, nausea, vomiting, tightness in chest, flank pain, red or black urine, and progressive signs of shock and renal failure.

Answer to Question 2

ANS: A
As a result of the immunocompromise that is associated with human immunodeficiency virus infection, the prevention of infection is paramount. Although certain precautions are justified in limiting exposure to infection, these must be balanced with the concern for the child's normal developmental needs. Restoring immunologic defenses is not currently possible. Current drug therapy is affecting the disease progression; although not a cure, these drugs can suppress viral replication, preventing further deterioration. Case finding is not a priority nursing goal.