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 C

Explanation

c. Sip the water he is allowed to have slowly to make it last throughout the day.

Option a is not recommended as hard candies may contain sugar and artificial sweeteners, which can be harmful to the patient's health.

Option b is not recommended because caﬀeinated tea has diuretic properties that can increase urine output, leading to further dehydration.

Option d is not recommended as Gatorade is a sports drink that contains high amounts of sugar and electrolytes, which can lead to ﬂuid overload and imbalances.

Sipping the water slowly can help the patient moisten his mouth without going over his ﬂuid restriction. This approach can also help him pace his ﬂuid intake throughout the day, which can be beneficial for maintaining proper hydration levels and managing ﬂuid overload.

A. Patient will exchange cigaretes for vaping in 5 days B. Patient will stop smoking cigaretes within 7 days C. Patient will smoke only a few cigaretes each day D. Patient will not smoke cigaretes while wearing oxygen

Correct Answer is D

Explanation

This outcome is the most appropriate because smoking can worsen COPD and lead to further respiratory complications, while oxygen is often used to help patients with COPD breathe more easily. Smoking while wearing oxygen can be very dangerous and increases the risk of fire and explosion. Therefore, the best expected outcome is for the patient to completely avoid smoking while wearing oxygen.

Option a is not a recommended solution since vaping may also worsen COPD symptoms and there is limited evidence of its safety in people with respiratory conditions. Option b is a good outcome, but it may not be achievable in such a short time frame. Option c is not an ideal outcome as even a few cigaretes can cause harm to the respiratory system, exacerbate symptoms, and slow down the healing process.

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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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