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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A) Tuna: Tuna is a major source of magnesium. It is a type of fish that contains a significant amount of this mineral. Magnesium plays a crucial role in various physiological functions, including muscle and nerve function, blood sugar regulation, and bone health. Including tuna in the diet can help maintain adequate magnesium levels.

B) Tomatoes: While tomatoes are nutritious and provide various vitamins and minerals, including potassium and vitamin C, they are not considered a major source of magnesium. Magnesium-rich foods are typically those that are high in seeds, nuts, whole grains, and leafy green vegetables.

C) Eggs: Eggs are a good source of several nutrients, including protein, vitamins, and minerals like vitamin D and choline. However, they are not particularly high in magnesium compared to other foods like nuts, seeds, and leafy greens.

D) Oranges: Oranges are well-known for their vitamin C content and are a good source of dietary fiber. However, they are not considered a major source of magnesium. Magnesium-rich foods are typically those that are more plant-based, such as nuts, seeds, and green leafy vegetables.

A. Dysrhythmias B. Dilated pupils C. Gastric ulcer D. Diarrhea

Correct Answer is A

Explanation

A) Dysrhythmias:
Straining while defecating can trigger the Valsalva maneuver, which involves taking a deep breath and bearing down. This can lead to increased intrathoracic pressure, decreased venous return to the heart, and subsequently a sudden drop in blood pressure when the strain is released. These changes can cause cardiac dysrhythmias, particularly in older adults or those with underlying heart conditions.

B) Dilated pupils:
Dilated pupils are not a known consequence of straining while defecating. Pupillary dilation is typically associated with responses to low light, certain medications, or neurological conditions, rather than gastrointestinal strain.

C) Gastric ulcer:
Gastric ulcers are caused by factors such as Helicobacter pylori infection, prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), or excessive stomach acid. Straining during defecation does not contribute to the development of gastric ulcers.

D) Diarrhea:
Straining while defecating is more likely to be associated with constipation rather than diarrhea. Diarrhea involves frequent, loose, or watery stools, whereas straining typically occurs due to hard stools and difficulty passing them.

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Nursing Test Bank

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