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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: While lift pads can help reduce the risk of workplace injuries for staff, such as pulled muscles, this is not their primary purpose. The main goal of using lift pads is to protect the client from injury during repositioning. Lift pads distribute the client’s weight more evenly, making it easier for staff to move them without straining themselves.

Choice B reason: Lift pads are not designed to absorb urinary incontinence or contain stool. There are specific products like incontinence pads and briefs for managing urinary and fecal incontinence. Lift pads are primarily used to assist with the safe repositioning of immobile clients.

Choice C reason: The primary purpose of lift pads is to help prevent friction and shearing when repositioning the client. Friction and shearing can cause skin damage and pressure ulcers, especially in immobile clients. Lift pads reduce the risk of these injuries by allowing smoother and safer movements.

Choice D reason: Lift pads do not prevent clients from being diaphoretic (sweating excessively). Diaphoresis can be managed through other means, such as adjusting room temperature, using fans, or providing appropriate clothing and bedding. Lift pads are not intended for this purpose.

A. Starting chest compressions B. Obtaining a central line C. Completing a comprehensive assessment D. Providing rescue breathing

Correct Answer is A

Explanation

Choice A reason: Starting chest compressions is the priority intervention for a client who is unresponsive, not breathing, and without a pulse. This situation indicates cardiac arrest, and immediate chest compressions are crucial to maintain circulation and oxygen delivery to vital organs. Early initiation of chest compressions improves the chances of survival and neurological outcomes.

Choice B reason: Obtaining a central line is not an immediate priority in the context of cardiac arrest. While central lines are important for administering medications and fluids, the first step in resuscitation is to establish effective chest compressions. Central line placement can be considered after initial resuscitation efforts are underway.

Choice C reason: Completing a comprehensive assessment is important, but it is not the immediate priority in a cardiac arrest situation. The primary focus should be on initiating chest compressions and basic life support measures. A detailed assessment can be performed once the client is stabilized.

Choice D reason: Providing rescue breathing is part of cardiopulmonary resuscitation (CPR), but it should follow the initiation of chest compressions. Current guidelines emphasize the importance of starting chest compressions immediately and then integrating rescue breaths. Effective chest compressions are the foundation of CPR.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

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