A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse?
The nurse collects a urine specimen.
The nurse starts the transfusion of another unit of blood product.
The nurse initiates an infusion of 0.9% sodium chloride.
The nurse sends a blood specimen to the laboratory.
The Correct Answer is B
A. Collect urine specimen
Appropriate to assess for hemoglobinuria during a hemolytic reaction.
B. Starts another unit of blood
Incorrect action—transfusion must be stopped and not restarted without provider evaluation.
C. Initiates 0.9% sodium chloride infusion
Maintains vascular access and supports renal perfusion-appropriate.
D. Sends blood specimen
Required for follow-up testing and identification of reaction cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "It sounds like it has been very challenging to find a job."
This response uses therapeutic communication. It reflects the client’s feelings and encourages further sharing. It shows empathy and supports emotional validation.
B. "I'm sure someone will call you next week."
This offers false reassurance, which is non-therapeutic. It doesn't address the client’s emotional needs and may hinder open communication.
C. "Don't worry. There are plenty of jobs out there."
This minimizes the client’s concern and dismisses their current struggle. It’s a non-therapeutic response.
D. "You need to apply for more jobs."
This response is directive and judgmental. It doesn't acknowledge the client’s current emotional state.
Correct Answer is D
Explanation
A. Apply ice packs to affected leg.
Cold therapy is not appropriate for DVT; it can worsen vasoconstriction.
B. Massage the affected leg twice a day.
Contraindicated. Massage can dislodge the clot and cause pulmonary embolism.
C. Have the client ambulate before applying anti-embolic stockings.
Stockings should be applied before ambulation to reduce risk of embolism.
D. Keep the affected leg elevated while in bed.
Promotes venous return, reduces swelling, and is appropriate for DVT management.
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