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
Booster seats are recommended for children between the ages of 4 and 8, or until they are 4'9" tall. This is because seat belts are designed for adults and may not properly fit a child's smaller body. A booster seat helps to position the seat belt correctly on the child's body, improving the effectiveness of the seat belt and reducing the risk of injury in the event of a crash.
Option a is incorrect because 10 years old is too old to need a car seat. Option b is incorrect because children under the age of 8, or under 4'9" tall, should not use a seat belt alone. Option d is incorrect because car seats are recommended until children are at least 4 years old, not 3.
Correct Answer is A
Explanation
A. Respiratory acidosis.
COPD is a chronic lung disease that can lead to an accumulation of carbon dioxide (CO2) in the body. This can cause respiratory acidosis, a condition in which the blood pH is lower than normal due to an excess of CO2.
In respiratory acidosis, the partial pressure of carbon dioxide (PaCO2) in the blood is increased and the pH is decreased. The kidneys atempt to compensate for the acidosis by excreting more acid in the urine and retaining more bicarbonate, but this compensation is usually not enough to fully correct the problem.
Metabolic alkalosis (option B) is a condition in which the blood pH is higher than normal due to an excess of bicarbonate in the blood. This is usually caused by loss of acid from the body, such as through vomiting or use of diuretics.
Respiratory alkalosis (option C) is a condition in which the blood pH is higher than normal due to a decrease in PaCO2. This can be caused by hyperventilation, which leads to excessive elimination of CO2 from the lungs.
Metabolic acidosis (option D) is a condition in which the blood pH is lower than normal due to an excess of acid in the blood. This can be caused by a variety of factors, including kidney failure or lactic acidosis.
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