A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
Administer oxygen to the client.
Collect a urine sample.
Check the client's vital signs.
Stop the infusion.
The Correct Answer is D
The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse should stop the infusion immediately and disconnect the blood tubing from the IV catheter to prevent further exposure to the incompatible blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should assess the client's gag reflex before allowing oral intake to prevent aspiration. The client's throat may be numb after a bronchoscopy, which is a procedure that uses a thin tube with a camera and light to examine the lungs and airways . The other actions are important but not the priority.
Correct Answer is D
Explanation
Wear a lead apron when providing client care. Internal radiation therapy (brachytherapy) is a type of treatment that uses a radioactive source placed inside or near the tumor . The nurse should wear a lead apron to protect themselves from exposure to radiation when caring for the client. The other actions are not appropriate for a client receiving internal radiation therapy.
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