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 C
Explanation
A. Disenfranchised grief:
Disenfranchised grief occurs when the loss experienced by an individual is not openly acknowledged or socially supported. This type of grief may occur when the relationship with the deceased is not recognized or valued by others, such as in the case of a non-traditional relationship. In this scenario, the client's grief is acknowledged but persists beyond what is considered a typical mourning period, suggesting a different type of grief.
B. Anticipatory grief:
Anticipatory grief occurs when individuals experience feelings of loss before the actual loss or death occurs. This often happens in situations where death is expected due to a terminal illness. Since the client's partner has already died, anticipatory grief does not apply in this case.
C. Prolonged grief:
This is the correct answer. Prolonged grief, also known as complicated grief, occurs when the grieving process persists over an extended period, beyond what is considered typical or socially acceptable. Individuals experiencing prolonged grief may have difficulty accepting the reality of the loss and may continue to experience intense emotions related to the loss for an extended period, often interfering with their daily functioning.
D. Uncomplicated grief:
Uncomplicated grief refers to a normal and typical response to loss that typically resolves over time. While grief is a natural response to loss, uncomplicated grief does not persist for an extended period or significantly impair the individual's ability to function in their daily life. In this scenario, the client's continued inability to accept the loss suggests that the grief may be more complex than uncomplicated grief.
Correct Answer is A
Explanation
A) Viral infection:
Chronic stress can suppress the immune system, making individuals more susceptible to infections, including viral infections. Prolonged stress can dysregulate the immune response, leading to increased vulnerability to various illnesses.
B) Increased cognitive awareness:
Chronic stress often impairs cognitive function rather than enhancing it. It can lead to difficulties with concentration, memory problems, and cognitive fatigue due to the continuous activation of the body's stress response system.
C) Hypotension:
Chronic stress typically leads to increased blood pressure rather than hypotension. Stress activates the sympathetic nervous system, resulting in the release of stress hormones like cortisol and adrenaline, which can elevate blood pressure over time.
D) Increased energy:
While acute stress can trigger a temporary surge in energy due to the release of stress hormones, chronic stress often leads to fatigue and exhaustion. Prolonged activation of the stress response system can deplete energy reserves and disrupt sleep patterns, resulting in feelings of fatigue and lethargy.
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