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
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Correct Answer is A
Explanation
The nurse should hang the drainage bag below the level of the client's abdomen to facilitate gravity drainage of fluid and waste products from the peritoneal cavity. The other options are incorrect because they may cause discomfort, infection, or inadequate dialysis.
Correct Answer is A
Explanation
The nurse should measure the client's blood pressure first, as sinus bradycardia can cause hypotension and decreased perfusion to vital organs. The nurse should assess the client's hemodynamic status and symptoms before initiating any interventions that may affect their heart rate or rhythm. The other options may be appropriate depending on the severity of the bradycardia and its underlying cause, but they are not the first priority.
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