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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

This is because older adults are at increased risk of hypothermia, which is a potentially life-threatening condition that occurs when the body temperature drops below 35° C (95° F).

Hypothermia can cause confusion, drowsiness, slurred speech, slow heartbeat, shallow breathing, and loss of consciousness. Some factors that increase the risk of hypothermia in older adults are low indoor temperature, inadequate clothing, poor nutrition, chronic illness, medication use, and social isolation.

The nurse should contact the local Department of Health and Human Services for the client to help them access resources and programs that can assist them with paying their heating bills or finding alternative housing options. The nurse should also educate the client on how to prevent hypothermia by wearing warm clothing, eating well-balanced meals, drinking warm fluids, avoiding alcohol and caffeine, and staying active.

A. Platelets 95,000/mm B. MCT 42% C. WBC count 8,000/mm D. INR of 1.6

Correct Answer is A

Explanation

A platelet count of 95,000/mm is below the normal range of 150,000 to 400,000/mm and indicates thrombocytopenia, which increases the risk of bleeding during surgery. The nurse should report this value to the surgeon and anticipate interventions such as transfusion of platelets or postponement of surgery. The other values are within normal limits and do not require immediate attention.

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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?

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Correct Answer is B

Explanation

A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon?

Correct Answer is A

Explanation

A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility?

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A nurse is caring for a group of clients. The nurse should obtain a blood pressure reading using only the left extremity from which of the following clients?