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
Related Questions
Correct Answer is C
Explanation
A PICC line is a long, thin tube that’s inserted through a vein in your arm and passed through to the larger veins near your heart 1. If the PICC line is touching a chamber of the heart, it is most likely touching the right atrium 2.
Correct Answer is A
Explanation
Before pumping the medication into the chamber, you should educate the patient to exhale. This means that the patient should breathe out fully before using the inhaler. This helps to empty the lungs of air and create more space for the medication to be inhaled.
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