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 C
Explanation
Choice A rationale
Administering oxygen via face mask is a common intervention for many complications during labor. However, it is not the first-line intervention for late decelerations. Late decelerations are a sign of fetal distress, often due to uteroplacental insufficiency. While oxygen can help increase oxygenation to the fetus, it does not address the root cause of the problem.
Choice B rationale
Elevating the patient’s legs is not typically the priority action when late decelerations are noted. This action would not alleviate the cause of late decelerations.
Choice C rationale
Having the patient turn to a side-lying position is often the first intervention when late decelerations are noted. This position helps increase blood flow to the placenta, potentially alleviating uteroplacental insufficiency and improving fetal oxygenation.
Choice D rationale
Increasing the infusion rate of IV fluids is not the first-line intervention for late decelerations. While it may be part of the management plan, it is not the priority action.
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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