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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
Chest physiotherapy can help loosen secretions that may not be audible with a stethoscope. This can help improve the patient’s breathing and overall lung function.
Correct Answer is B
Explanation
Choice A reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Three defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.
Choice B reason: This is correct because it shows that the PN is familiar with the nursing diagnosis criteria. One defining characteristic is the least number required for the diagnosis of Impaired Verbal Communication, according to the NANDA-I taxonomy.
Choice C reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Four defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.
Choice D reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Two defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.
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