Answer to Question 1
ANS: 3
Chvostek's sign is seen with hypocalcemia. Rapid administration of blood transfusions contain-ing citrate may cause hypocalcemia. Citrate solution is used to prevent clotting of the blood so that it can be stored in the refrigerator until it is needed for transfusion. Also, if blood that is cold is administered too rapidly, it may cause cardiac dysrhythmias. If a client receives a rapid blood transfusion, the kidneys may not be able to excrete phosphorus quickly enough and the phos-phorus level increases while the calcium level decreases. Sepsis may also increase the risk for de-veloping hypocalcemia. The client who has a rapid blood transfusion of citrated blood would not be expected to experience excessive sweating. The client who experiences an anaphylactic reac-tion or sepsis typically has cool, clammy skin. Anxiety may be related to an anaphylactic or fe-brile, nonhemolytic reaction to a blood transfusion. However, it is not the best indication of a possible reaction because the client may be anxious because of receiving a blood transfusion, having nothing to do with a physiological reaction to the transfusion. Nausea and vomiting may or may not indicate a reaction to a blood transfusion.
Answer to Question 2
ANS: 2
Hypertension is a symptom of fluid volume excess. A weak, thready pulse is associated with fluid volume deficit. A bounding pulse is a symptom of fluid volume excess. Dry mucous mem-branes and flushed skin are both symptomatic of fluid volume deficit, not excess.
NURSE
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Average optimal blood pressure for age
To check pupillary reflexes the nurse first holds the penlight
Measuring Blood Pressure