A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

Stop the transfusion.

Notify the health care provider of the client s response.

Check the client s vital signs.

Document the findings.

Answer and Explanation

The Correct Answer is A

Difficulty breathing is a sign of a potential transfusion reaction. When a client reports difficulty breathing during a blood transfusion, the nurse should stop the transfusion immediately to prevent the reaction from worsening. Once the transfusion is stopped, the nurse can then assess the client's vital signs and notify the healthcare provider of the client's response. Documentation of the findings should also be completed after the client's condition has stabilized. However, stopping the transfusion takes priority over documenting the findings.

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Correct Answer is A

Explanation

A. This is the most appropriate response. Clients with COPD often have chronically elevated carbon dioxide levels, which can lead to a compensatory decrease in the oxygen saturation level. A reading of 91% may be within their normal range.

A. give the ﬂuids quickly. B. monitor the amount of ﬂuid the client is receiving. C. if the ﬂuids are too low. increase them to infuse quicker. D. check the intravenous rate every two days.

Correct Answer is B

Explanation

: A client with renal disease may have impaired kidney function, which can aﬀect ﬂuid balance in the body. Giving ﬂuids too quickly or increasing the infusion rate too quickly can lead to ﬂuid overload,

which can exacerbate the client's condition. It is important for the nurse to monitor the amount of ﬂuid the client is receiving to ensure that the infusion rate is appropriate for the client's condition and to prevent ﬂuid overload. Checking the intravenous rate every two days is not sufficient; the nurse should monitor the rate regularly and adjust it as necessary based on the client's response.

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A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

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Naxlex Comprehensive Predictor Exams

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