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 D

Explanation

Sitting the patient up and encouraging deep breathing can help improve oxygenation and increase the pulse oximetry reading. This is a non-invasive intervention that can be implemented immediately to help improve the patient’s oxygen levels.

A. Hyperkalemia B. Hypocalcemia C. Thrombocytopenia D. Anemia E. Hyponatremia

Correct Answer is ["A","B","E"]

Explanation

These are all electrolyte imbalances. Hyperkalaemia is an elevated level of potassium in the blood. Hypocalcaemia is a low level of calcium in the blood. Hyponatremia is a low level of sodium in the blood. Thrombocytopenia and anemia are not electrolyte imbalances. Thrombocytopenia is a low platelet count and anemia is a low red blood cell count or low hemoglobin levels.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is ["A","B","E"]

Explanation

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