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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale

Waiting until the next appointment could potentially put both the mother and the baby at risk. Leakage of vaginal fluid could indicate premature rupture of membranes, which can lead to infection or premature labor.

Choice B rationale

While fetal movement is a good sign, it does not rule out potential complications associated with leakage of vaginal fluid. Therefore, this advice could lead to a delay in necessary medical intervention.

Choice C rationale

This is the most appropriate response. Leakage of vaginal fluid in a pregnant woman could be a sign of premature rupture of membranes, which can lead to complications such as infection or premature labor. Immediate medical attention is necessary to assess the situation and take appropriate action.

Choice D rationale

Asking the client to wait and see if the leakage changes could potentially delay necessary medical intervention. It’s important to seek immediate medical attention to assess the situation and take appropriate action.

A. “Taking the medication between meals will help you absorb the medication more efficiently.”. B. “The medication can cause nausea if taken with food.”. C. “Taking the medication with food increases the risk of esophagitis.”. D. “Taking the medication between meals will help you avoid becoming constipated.”.

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.

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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?

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Naxlex Comprehensive Predictor Exams

A 23 weeks pregnant client calls the clinic and reports leakage of vaginal fluid.What should be the appropriate response by the nurse?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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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?