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) 41-year-old with hypernatremia:
Hypernatremia refers to elevated levels of sodium in the blood. While hypernatremia can lead to dehydration and electrolyte imbalances, it does not directly correlate with an increased risk of hypomagnesemia.
B) 72-year-old with chronic alcoholism:
Chronic alcoholism is a significant risk factor for hypomagnesemia. Alcohol abuse can lead to poor dietary intake of magnesium, increased renal excretion of magnesium, and impaired absorption of magnesium in the gastrointestinal tract, all contributing to magnesium deficiency.
C) 79-year-old with bone cancer:
Bone cancer does not inherently increase the risk of hypomagnesemia. However, depending on the treatment modalities and disease progression, the client may be at risk for other electrolyte imbalances or complications associated with bone cancer.
D) 46-year-old with respiratory acidosis:
Respiratory acidosis refers to an acid-base imbalance characterized by elevated levels of carbon dioxide in the blood due to impaired ventilation. While respiratory acidosis can lead to electrolyte imbalances, particularly potassium imbalances, it is not directly linked to hypomagnesemia.
Correct Answer is C
Explanation
A. Airborne:
Airborne precautions are used for infections transmitted via small droplet nuclei that remain suspended in the air for long periods and can be inhaled by others. Examples of diseases requiring airborne precautions include tuberculosis, measles, and chickenpox. Pertussis is not transmitted via the airborne route.
B. Contact:
Contact precautions are used for infections spread by direct or indirect contact with the client or their environment. Examples include Clostridioides difficile, methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). Pertussis is primarily spread through respiratory droplets rather than contact with contaminated surfaces.
C. Droplet:
Pertussis is primarily spread through respiratory droplets when an infected person coughs or sneezes. The nurse should initiate droplet precautions to prevent the transmission of the bacteria to others. These include wearing a surgical mask when within 3 feet of the client, placing the client in a private room or cohorting with another client who has the same infection, and ensuring that visitors wear masks and practice hand hygiene.
D. Protective:
Protective precautions, also known as reverse isolation, are used to protect clients who have compromised immune systems from exposure to pathogens. This precaution is not relevant for a client with pertussis; instead, the focus is on preventing transmission to others through droplet precautions.
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