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 C
Explanation
Palpating the site for a thrill is an important action to assess the patency and function of an arteriovenous graft, which is a synthetic tube that connects an artery and a vein for hemodialysis access. A thrill is a vibration felt over the graft that indicates blood flow. The other options are incorrect because they could compromise or damage the graft.
Correct Answer is B
Explanation
This indicates hyperkalemia, which is a common complication of severe burn injuries due to massive cell destruction and fluid lossfrom damaged tissues. Hyperkalemia can lead to cardiac dysrhythmias and arrest, which are signs of hypovolemic shock.
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