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. Turn the client on his side before starting oral care: This is the correct action. Turning the client on their side helps prevent aspiration of oral secretions or fluids during oral care, especially for an immobile client who may have difficulty swallowing or managing oral secretions effectively. Positioning the client on their side also facilitates better access to the oral cavity for oral care procedures.

B. Use the thumb and index finger to keep the client's mouth open: Using the thumb and index finger to keep the client's mouth open may cause discomfort or injury to the client. Instead, it's essential to encourage the client to open their mouth gently or use an appropriate oral device to keep the mouth open during oral care.

C. Apply petroleum jelly to the client's lips after oral care: Applying petroleum jelly to the client's lips after oral care can help keep the lips moisturized and prevent dryness. However, it is not the most immediate action necessary for oral care. Ensuring proper positioning and cleaning of the oral cavity take precedence during oral care for an immobile client.

D. Use a stiff toothbrush to clean the client's teeth: Using a stiff toothbrush can cause damage to the client's oral tissues, especially if the client has impaired oral hygiene or compromised oral health. It's essential to use a soft-bristled toothbrush or sponge swabs for oral care to prevent injury or trauma to the oral mucosa, especially in clients who are immobile.

A. "It's a good idea to help make sure your husband can sleep comfortably." B. "Why do you think your husband needs more medication when he is asleep?" C. "Next time you think he needs more medication, call me and I'll push the button." D. "Your husband should decide when more medication is needed."

Correct Answer is D

Explanation

A) "It's a good idea to help make sure your husband can sleep comfortably.":
This encourages the partner to administer medication, which can lead to overmedication and potential harm.

B) "Why do you think your husband needs more medication when he is asleep?":
This might cause the partner to feel defensive. It also does not provide the necessary education about the correct use of the PCA pump.

C) "Next time you think he needs more medication, call me and I'll push the button.":
This is inappropriate as well. It does not address the core issue that only the patient should be pressing the button to ensure safe and appropriate use of the PCA pump.

D) "Your husband should decide when more medication is needed.":
This educates the partner about the proper use of the PCA pump, emphasizing that only the patient should press the button to ensure they are receiving medication only when they feel pain. This minimizes the risk of overmedication and adverse effects.

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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

Naxlex Comprehensive Predictor Exams

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is using a patient-controlled analgesia (PCA) pump for postoperative pain management. The nurse enters the room to find the client asleep and his partner pressing the button to dispense another dose. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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