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 A
Explanation
Choice A rationale
Taking ferrous sulfate between meals can help increase absorption of the medication. Iron is best absorbed on an empty stomach. However, it may need to be taken with food to reduce stomach upset.
Choice B rationale
While it’s true that ferrous sulfate can cause nausea, this is not the primary reason for taking it between meals. The main goal is to enhance absorption.
Choice C rationale
There’s no evidence to suggest that taking ferrous sulfate with food increases the risk of esophagitis.
Choice D rationale
While constipation can be a side effect of ferrous sulfate, taking it between meals does not necessarily prevent this.
Correct Answer is A
Explanation
Choice A rationale
Magnesium sulfate is used in preterm labor to suppress contractions and delay the birth of a preterm baby. It works by lowering the amount of calcium in the uterine muscles, which in turn encourages muscle relaxation. This effect can help slow or inhibit contractions, allowing more time for the administration of corticosteroids before birth. Corticosteroids can improve a baby’s lung function and reduce the risk of dying by 40 percent if given within 48 hours. Therefore, magnesium sulfate is used to stop preterm labor contractions.
Choice B rationale
Magnesium sulfate does not directly increase the fetal heart rate. Its primary role in the context of preterm labor is to inhibit contractions.
Choice C rationale
While magnesium sulfate is used in the context of preterm labor, it does not directly promote fetal lung maturity. However, by delaying delivery, it allows more time for the administration of corticosteroids, which can enhance the baby’s lung function.
Choice D rationale
While magnesium sulfate can have a muscle-relaxing effect, its primary use in the context of preterm labor is not to promote relaxation or alleviate anxiety in the mother. Its main role is to inhibit uterine contractions.
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