The nurse is assisting in monitoring a client who is receiving a ...

[SO00]

The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs).
 
  Before leaving the room, the nurse tells the client that it is most important to immediately report which of the following symptoms of a transfusion reaction, if they occur? Select all that apply. 1. Chills
  2. Sleepiness
  3. Fatigue
  4. Chest pain
  5. Low back pain
  6. Difficulty breathing

Question 2

An adolescent is seen in the emergency department following an athletic injury. It is suspected that the child has sprained an ankle. X-rays have been obtained, and a fracture has been ruled out.
 
  The nurse is providing instructions to the adolescent regarding home care for treatment of the sprain. Which of the following instructions would the nurse provide to the adolescent? 1. Elevate the extremity, and maintain strict bed rest for a period of 7 days.
  2. Immobilize the extremity, and maintain the extremity in a dependent position.
  3. Apply heat to the injured area every 4 hours for the first 48 hours, and then begin to apply ice.
  4. Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 to 48 hours.

[ju]

Answer to Question 1

1, 4, 5, 6

Rationale: The nurse should instruct the client to immediately report signs of a transfusion reac-tion, which can include chest pain, lower back pain, chills, itching, rash, or difficulty breathing. These signs of transfusion reaction would require the nurse to stop the transfusion. Fatigue and sleepiness are unrelated to transfusion reaction.

Answer to Question 2

4

Rationale: The injured area should be wrapped immediately to support the joint and control the swelling. Ice is applied to reduce the swelling and should be applied for not longer than 30 minutes every 4 to 6 hours for the first 24 to 48 hours. The joint should be immobilized and ele-vated, but strict bed rest for a period of 7 days is not required. A dependent position will cause swelling in the affected area.

[SO00]

Thank you!

[ju]

Always glad to help...