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:
“Records that the client sees the procedure as necessary” is incorrect. The nurse’s role in signing the consent form is not to document the client’s perception of the necessity of the procedure. This responsibility typically falls to the healthcare provider who explains the procedure and its necessity to the client.
Choice B Reason:
“Determines the client does not have a mental illness” is incorrect. While assessing the client’s mental status is part of the overall care, the nurse’s signature on the consent form does not specifically indicate this. The nurse’s role is to witness the client’s signature and ensure they are giving informed consent.
Choice C Reason:
“Assists that the nurse has explained the risks and benefits of the procedure” is incorrect. It is the responsibility of the healthcare provider performing the procedure to explain the risks and benefits. The nurse may reinforce this information but does not primarily provide it.
Choice D Reason:
“Confirms the client is competent to provide consent” is correct. The nurse’s signature on the consent form indicates that the nurse has witnessed the client signing the form and has verified that the client is competent to provide informed consent. This includes ensuring the client understands the information provided and is making the decision voluntarily.
Correct Answer is B
Explanation
Choice A Reason:
Prolonging the life of a client is not the primary focus of palliative care. While palliative care can sometimes extend life by improving overall well-being and reducing stress, its main goal is to enhance the quality of life by managing symptoms and providing comfort12. Palliative care is not primarily aimed at life extension but rather at ensuring that patients live as well as possible despite their illness.
Choice B Reason:
Controlling symptoms and providing comfort is the core focus of palliative care. This type of care aims to alleviate pain and other distressing symptoms, such as nausea, shortness of breath, and fatigue12. Palliative care also addresses emotional, social, and spiritual needs, helping patients and their families cope with the challenges of serious illness. By focusing on comfort and quality of life, palliative care supports patients in living as fully as possible.
Choice C Reason:
Replacing other treatments for an illness is not the focus of palliative care. Palliative care is designed to complement, not replace, other medical treatments12. It can be provided alongside curative or life-prolonging treatments, offering additional support to manage symptoms and improve quality of life. The goal is to provide a holistic approach to care that addresses all aspects of a patient’s well-being.
Choice D Reason:
Curing a serious illness is not the aim of palliative care. Palliative care is appropriate for patients at any stage of a serious illness, whether or not a cure is possible12. Its primary focus is on symptom management, comfort, and quality of life, rather than on curing the illness. This approach helps patients and their families navigate the complexities of serious health conditions with greater ease and support.
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