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 B
Explanation
Choice A Reason:
Securing the oxygen tubing to the bed sheet near the client’s head is not recommended because it can lead to accidental dislodgement of the tubing, which can interrupt the oxygen supply. Additionally, this practice does not address the potential for nasal dryness and irritation that can occur with oxygen therapy. Properly securing the tubing should involve ensuring it is comfortably positioned and not at risk of being pulled or dislodged.
Choice B Reason:
Attaching a humidifier bottle to the base of the flow meter is the correct action because it helps to add moisture to the oxygen being delivered to the client. Oxygen therapy, especially at higher flow rates like 5 L/min, can dry out the nasal passages and mucous membranes, leading to discomfort and potential complications. The humidifier bottle ensures that the oxygen is humidified, which helps to prevent dryness and irritation, making the therapy more comfortable and effective for the client.
Choice C Reason:
Applying petroleum jelly to the nares is not recommended because petroleum-based products can be flammable and pose a risk when used in conjunction with oxygen therapy. Additionally, petroleum jelly can trap bacteria and potentially lead to infections. Instead, water-based lubricants or saline nasal sprays are safer alternatives for soothing dry nasal passages.
Choice D Reason:
Removing the nasal cannula while the client eats is not advisable because it interrupts the continuous delivery of oxygen, which is essential for clients with pneumonia who may already have compromised respiratory function. Instead, the nurse should ensure that the nasal cannula is securely in place and that the client is receiving the prescribed oxygen therapy at all times, including during meals.
Correct Answer is C
Explanation
Choice A Reason:
Lubricate the suction catheter tip with sterile saline is important to ensure smooth insertion and reduce trauma to the tracheal mucosa. However, this is not the first step. Preoxygenation is crucial to prevent hypoxia during the suctioning process.
Choice B Reason:
Perform chest physiotherapy prior to suctioning can help mobilize secretions, making them easier to remove. While beneficial, it is not the immediate first step. Ensuring the client is adequately oxygenated takes precedence.
Choice C Reason:
Hyperventilate the client on 100% oxygen prior to suctioning is correct. This step is essential to prevent hypoxia during suctioning. Suctioning can temporarily reduce oxygen levels, so preoxygenating the client helps maintain adequate oxygenation throughout the procedure.
Choice D Reason:
Suction two to three times with a 60-second pause between passes is a recommended practice to allow the client to recover between suctioning attempts. However, this step follows the initial preoxygenation.
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