A nurse is administering platelets to a client who reports having lower back pain and feeling chilled and itchy. Which of the following actions should the nurse take first?
Collect a urine sample from the client
Return the platelet bag and tubing to the blood bank
Notify the provider
Stop the infusion
The Correct Answer is D
A. Collect a urine sample from the client: While collecting a urine sample may be necessary for further assessment, it is not the priority in this situation. The client's symptoms of lower back pain, feeling chilled, and itching suggest a potential transfusion reaction, which requires immediate attention to ensure the client's safety. Therefore, collecting a urine sample is not the most appropriate initial action.
B. Return the platelet bag and tubing to the blood bank: Returning the platelet bag and tubing to the blood bank may be necessary after stopping the infusion, but it is not the first action the nurse should take. Stopping the infusion and assessing the client's condition are the immediate priorities to address the potential transfusion reaction.
C. Notify the provider: While it is important to notify the provider about the client's symptoms and the suspected transfusion reaction, this action should follow after stopping the infusion and assessing the client's condition. Immediate intervention to ensure the client's safety takes precedence over contacting the provider.
D. Stop the infusion: This is the correct action. The client's symptoms of lower back pain, feeling chilled, and itching are indicative of a potential transfusion reaction, such as febrile non-hemolytic transfusion reaction or allergic reaction. The immediate priority is to stop the infusion to prevent further administration of platelets and assess the client's condition. This action takes precedence over other interventions as addressing the client's safety and well-being is paramount in the event of a transfusion reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) The client with end-stage renal failure scheduled for dialysis is at risk for fluid volume excess rather than deficit. Dialysis is a treatment to remove excess fluid and waste products from the body, which can lead to fluid volume deficit if not managed appropriately, but the scenario does not indicate current dehydration.
B) The client with gastroenteritis and fever is at risk for fluid volume deficit due to fluid loss from vomiting, diarrhea, and fever-induced diaphoresis. Gastroenteritis commonly leads to dehydration, especially when accompanied by fever, which increases fluid loss through sweating.
C) The client with left-sided heart failure and an elevated brain natriuretic peptide (BNP) level is at risk for fluid volume excess rather than deficit. Elevated BNP levels indicate heart failure, which can result in fluid retention and volume overload rather than deficit.
D) The client who has been NPO since midnight for endoscopy is at risk for fluid volume deficit due to fasting. However, the severity and duration of fasting are not specified in the scenario, so it may not present an immediate risk compared to the client with gastroenteritis and fever.
Correct Answer is B
Explanation
B) Placing clean linen that touched the floor in the soiled linen bag: This action demonstrates an understanding of infection control principles because it prevents cross-contamination between clean and soiled linens. Placing clean linens that have come into contact with the floor in the soiled linen bag reduces the risk of spreading pathogens and maintains a clean environment for the client.
A) Placing the soiled linen on the floor before bagging it: This action increases the risk of contamination by exposing the linen to potentially contaminated surfaces. Placing soiled linen on the floor can spread pathogens and is not consistent with infection control practices.
C) Holding the soiled linen against her body while carrying it to the linen bag: This action increases the risk of contamination to the AP's clothing and skin. Contact with soiled linen can transfer pathogens to the caregiver's body, leading to the potential spread of infection.
D) Shaking the soiled linen to remove any toilet paper remnants: This action can aerosolize fecal matter and spread pathogens into the air and onto nearby surfaces. Shaking soiled linen increases the risk of contamination and is not recommended as part of infection control practices.
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