A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low-back pain. After stopping the transfusion, which intervention is important to complete FIRST?
Call the provider.
Notify the blood bank.
Collect a urine specimen.
Keep the line open with 0.9% NS through new tubing.
The Correct Answer is D
Choice A Reason:
“Call the provider” is important but not the first priority. The immediate concern is to maintain the client’s intravenous access to ensure they can receive any necessary medications or fluids promptly. Once the line is secured, the provider should be notified to receive further instructions and manage the client’s condition.
Choice B Reason:
“Notify the blood bank” is also crucial but comes after ensuring the client’s immediate safety. The blood bank needs to be informed to investigate the cause of the reaction and prevent further issues, but this step follows the initial emergency interventions.
Choice C Reason:
“Collect a urine specimen” is necessary to check for hemolysis, which can occur during a transfusion reaction. However, this is not the first step. The priority is to stabilize the client by maintaining IV access with normal saline.
Choice D Reason:
“Keep the line open with 0.9% NS through new tubing” is the correct first intervention. This action ensures that the client remains hydrated and that the IV line is available for any emergency medications or treatments. Using new tubing prevents any contamination from the transfusion set.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
“Delivers a low concentration of oxygen” is incorrect because a nasal cannula can deliver varying concentrations of oxygen depending on the flow rate set by the healthcare provider. The concentration can range from low to moderate, typically between 24% to 44%.
Choice B Reason:
“Delivers a constant rate of oxygen” is partially correct but not entirely accurate. While the flow rate can be constant, the key aspect is the specific concentration of oxygen delivered, which is more relevant to the client’s understanding.
Choice C Reason:
“Delivers a high concentration of oxygen” is incorrect because nasal cannulas are generally used for low to moderate oxygen delivery. High concentrations of oxygen are typically delivered through other devices like non-rebreather masks or high-flow nasal cannulas.
Choice D Reason:
“Delivers a constant flow of a specific concentration of oxygen” is correct. This explanation accurately describes how a nasal cannula works. It provides a continuous flow of oxygen at a specific concentration, which is adjusted based on the client’s needs and the healthcare provider’s prescription.
Correct Answer is ["260"]
Explanation
-
Calculation
- Enteral nutrition: 200 mL
- Water flush before feed: 30 mL
- Water flush after feed: 30 mL
Total intake = 200 mL + 30 mL + 30 mL = 260 mL
The nurse should document 260 mL as intake in the I&O.
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