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 D

Explanation

Allow the client to sign the consent with an X. The client has the right to give informed consent if they understand the procedure and its risks and benefits, even if they cannot read or write. The nurse should witness and document the client's signature with an X and verify their identity and understanding. The other options are not appropriate because they violate the client's autonomy and dignity.

A. Recommend staying at a local shelter until the client can afford the bill. B. Contact the local Department of Health and Human Services for the client. C. Contact the client's family members to tell them the client's financial status. D. Provide the client with written information about the dangers of hypothermia.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who understands a prescribed surgical procedure, but cannot read or write. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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