A nurse is administering Packed Red Blood Cells (PRBC) to a client who reports having lower back pain and feeling chilled and itchy.
Which of the following actions should the nurse take first?
Return the platelet bag and tubing to the blood bank.
Stop the infusion.
Notify the provider.
Collect a urine sample from the client.
The Correct Answer is B
Choice A rationale
Returning the platelet bag and tubing to the blood bank is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which is a serious complication that requires immediate intervention.
Choice B rationale
Stopping the infusion is the first action the nurse should take when a client reports symptoms of a transfusion reaction. This is because continuing the transfusion could worsen the reaction and potentially lead to more serious complications.
Choice C rationale
While notifying the provider is an important step in managing a transfusion reaction, it is not the first action the nurse should take. The nurse should first stop the infusion to prevent further exposure to the blood product.
Choice D rationale
Collecting a urine sample from the client is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Tarry stools are not a typical manifestation of cirrhosis. They are more commonly associated with gastrointestinal bleeding.
Choice B rationale
Spider angiomas are a common manifestation of cirrhosis. They are small, dilated blood vessels with a bright red center point and radiating branches, and they are often found on the face, neck, and chest.
Choice C rationale
Moist skin is not a typical manifestation of cirrhosis. Cirrhosis can cause various skin changes, but they typically include jaundice, pruritus, and palmar erythema.
Choice D rationale
Blood in the urine is not a typical manifestation of cirrhosis. It is more commonly associated with urinary tract infections, kidney stones, or bladder disorders.
Correct Answer is A
Explanation
Choice A rationale
Hypoglycemia is a common complication in newborns, especially those who are 8 hours old. The newborn’s body has not yet fully developed the ability to regulate blood sugar levels, leading to hypoglycemia.
Choice B rationale
Neonatal abstinence syndrome is typically seen in newborns exposed to addictive illegal or prescription drugs while in the mother’s womb. Without additional context, it’s not clear if this applies to the newborn in question.
Choice C rationale
Hyperbilirubinemia, or jaundice, is a condition that can occur in newborns, usually a few days after birth. However, it’s less likely to develop within the first 8 hours of life.
Choice D rationale
Drug withdrawal symptoms are similar to neonatal abstinence syndrome and occur in newborns who have been exposed to certain drugs while in the womb. Again, without additional context, it’s not clear if this applies to the newborn in question.
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