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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Preventing musculoskeletal disability
Important, but not priority in life-threatening trauma.

B. Stabilizing cardiac arrhythmias
Secondary-ABCs take precedence.

C. Decreasing intracranial pressure
Important in head injury but only after airway is secure.

D. Airway protection
Airway is the priority in trauma (per ABCs: Airway, Breathing, Circulation).

A. A middle adult male who is diaphoretic and reports epigastric pain B. An adolescent female client who is belligerent and has slurred speech C. A young adult with a painful sunburn of his face and arms D. A toddler who has a laceration on his forehead and is screaming

Correct Answer is A

Explanation

A. Middle adult male who is diaphoretic and reports epigastric pain
Diaphoresis and epigastric pain can be atypical signs of an MI and require immediate evaluation.

B. Adolescent female who is belligerent and has slurred speech
Could be intoxicated, but not the most urgent.

C. Young adult with painful sunburn
Discomforting but not life-threatening.

D. Toddler with a forehead laceration screaming
Needs attention but is likely stable; crying indicates airway and consciousness are intact.

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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?

Nursing Test Bank

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