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 B
Explanation
Crackles, also known as rales, are discontinuous sounds that are typically heard during inspiration in patients with heart failure. These sounds are produced by the sudden opening of small airways and alveoli that are filled with fluid or collapsed due to pulmonary congestion. The sound can be described as similar to the sound of rubbing hair between fingers or the sound of Velcro being pulled apart.
Rhonchi are continuous, low-pitched sounds that are typically heard during expiration and are caused by the movement of air through narrowed airways, such as in patients with chronic obstructive pulmonary disease (COPD). Stridor is a high-pitched, continuous sound that is typically heard during inspiration and indicates upper airway obstruction, which can be life-threatening. Neither rhonchi nor stridor are typically heard in patients with heart failure.
Therefore, based on the patient's history and symptoms, the most likely type of breathing sound to be heard on auscultation is crackles/rales.
Correct Answer is A
Explanation
The use of an incentive spirometer is essential after surgery to prevent complications such as pneumonia and atelectasis. Atelectasis is the collapse of air sacs in the lungs, which can occur after surgery due to decreased respiratory effort and shallow breathing. An incentive spirometer helps the patient take deep breaths and increase their lung volume, preventing these complications.
Breathing rapidly to prevent pneumonia (option b) is not recommended as it can lead to hyperventilation and other respiratory complications.
Option c is incorrect because patient education is a crucial aspect of post-operative care, and the patient needs to be aware of the potential complications and how to prevent them.
The use of a chest tube (option d) is not usually required after hip surgery, and it is not a priority teaching for the patient.
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