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 B
Explanation
A. Office of Disease Prevention and Health Promotion (ODPHP)
Focuses on disease prevention through education, not direct food distribution.
B. U.S. Department of Agriculture (USDA)
The USDA provides food assistance programs like SNAP, WIC, and school lunches to improve food security.
C. U.S. Food and Drug Administration (FDA)
Regulates food and drug safety, not food distribution.
D. Health Resources and Services Administration (HRSA)
Focuses on health care access for underserved populations, not direct food support.
Correct Answer is ["A","B","C","E"]
Explanation
A. Edema of the extremities
Fluid accumulation due to poor cardiac output contributes to peripheral edema.
B. Jugular vein distention
Reflects elevated central venous pressure from fluid overload.
C. Tachypnea
Increased respiratory rate is a compensatory mechanism for impaired oxygen exchange.
D. Ascites
Associated with liver disease or right-sided heart failure, not specifically pulmonary edema.
E. Pink frothy sputum
Classic sign of pulmonary edema due to fluid in the alveoli.
F. Atelectasis
Can occur in respiratory illness but is not a hallmark sign of pulmonary edema.
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