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 D

Explanation

A) Irritable: Irritability is more closely associated with emotional responses to stress rather than cognitive responses. While irritability can be a manifestation of stress, it primarily reflects emotional tension rather than cognitive impairment.

B) Lethargic: Lethargy is a physical response to stress rather than a cognitive one. It refers to a lack of energy, motivation, or enthusiasm, which can result from stress-induced fatigue or exhaustion.

C) Angry: Anger is also primarily an emotional response to stress rather than a cognitive one. While stress can contribute to feelings of anger or frustration, it does not directly reflect cognitive impairment or alterations in cognitive functioning.

D) Decreased attention to detail: Cognitive responses to stress can include difficulty concentrating, decreased attention to detail, memory problems, and impaired decision-making. When a client demonstrates decreased attention to detail, it indicates cognitive impairment or distraction, which can be a response to stress. This behavior suggests that the client's cognitive functioning is affected by the stress they are experiencing.

A. Lavender B. Orange C. Peppermint D. Ginger

Correct Answer is A

Explanation

A. Lavender:
Lavender essential oil is well-known for its calming and relaxing properties. It is often used to promote sleep and alleviate insomnia symptoms. Research suggests that inhaling lavender aroma or using lavender oil in aromatherapy can help improve sleep quality by reducing anxiety and promoting relaxation.

B. Orange:
While orange essential oil has a refreshing and uplifting scent, it is not typically used to promote sleep. Instead, it is often used to boost mood and energy levels due to its citrusy aroma.

C. Peppermint:
Peppermint essential oil has a stimulating and invigorating scent, making it more suitable for promoting alertness and mental clarity rather than inducing sleep. It is commonly used to alleviate fatigue and increase focus.

D. Ginger:
Ginger essential oil has a warm and spicy aroma that is often used for its energizing and revitalizing effects. Similar to peppermint, ginger is not typically used to promote sleep but may help alleviate fatigue and increase mental alertness.

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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?

Nursing Test Bank

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