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 the insulin 30 minutes after breakfast is not recommended. Regular insulin should be administered before meals.
Choice B rationale
Administering the insulin at 0700 is not recommended. Regular insulin should be administered 30 to 45 minutes before a meal.
Choice C rationale
Administering the insulin at 0730 is recommended if breakfast is at 0800. Regular insulin should be administered 30 to 45 minutes before a meal. This is the correct answer.
Choice D rationale
Administering the insulin when the breakfast tray arrives is not recommended. Regular insulin should be administered 30 to 45 minutes before a meal.
Correct Answer is C
Explanation
Choice A rationale
Decreased follicle-stimulating hormone is not the major cause of the onset of menopause and the resulting atrophy of the vulvar organs. The major cause is decreased estrogen.
Choice B rationale
Increased levels of prostaglandin are not the major cause of the onset of menopause and the resulting atrophy of the vulvar organs. The major cause is decreased estrogen.
Choice C rationale
Decreased estrogen is the major cause of the onset of menopause and the resulting atrophy of the vulvar organs. During perimenopause, less estrogen may cause the tissues of the vulva and the lining of the vagina to become thinner, drier, and less elastic or flexible.
Choice D rationale
Increased luteinizing hormone is not the major cause of the onset of menopause and the resulting atrophy of the vulvar organs. The major cause is decreased estrogen.
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