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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Reminding the client that a signed informed consent form is a legally binding document is incorrect. Informed consent is based on the principle of patient autonomy, meaning the patient has the right to withdraw consent at any time. The nurse should respect the client’s decision and not pressure them into proceeding with the procedure.

Choice B reason: Notifying the surgeon that the client wishes to withdraw informed consent for the procedure is the appropriate action. The surgeon needs to be informed immediately so that they can discuss the client’s concerns, provide additional information if needed, and respect the client’s decision. This ensures that the client’s autonomy and rights are upheld.

Choice C reason: Proceeding with preparation of the patient for the surgical procedure is not appropriate once the client has withdrawn consent. Continuing with the preparation would violate the client’s rights and could lead to legal and ethical issues. The nurse must halt any further preparation and inform the relevant medical staff of the client’s decision.

Choice D reason: Informing the surgical team to cancel the client’s surgery is a step that may be taken after discussing the withdrawal of consent with the surgeon. The nurse should first notify the surgeon, who will then make the decision to cancel the surgery based on the client’s wishes. Directly informing the surgical team without consulting the surgeon first is not the correct protocol.

A. Cured fat food B. Vegetables C. Canned soups D. Processed snacks E. Sugary drinks

Correct Answer is ["A","C","D","E"]

Explanation

Choice A Reason:

Cured fat foods, such as bacon, sausages, and other processed meats, are high in saturated fats and sodium. Consuming these foods in excess can lead to increased cholesterol levels and a higher risk of heart disease. Limiting these foods is essential for maintaining a healthy diet and reducing the risk of chronic diseases.

Choice B Reason:

Vegetables are generally low in calories and high in essential nutrients, including vitamins, minerals, and fiber. They are an important part of a balanced diet and should not be limited. Instead, increasing vegetable intake is often recommended for better health outcomes.

Choice C Reason:

Canned soups often contain high levels of sodium, which can contribute to high blood pressure and other cardiovascular issues. Limiting the intake of canned soups can help manage sodium consumption and promote better heart health.

Choice D Reason:

Processed snacks, such as chips, crackers, and packaged baked goods, are typically high in unhealthy fats, sugars, and sodium. These foods can contribute to weight gain, high blood pressure, and other health problems. Reducing the intake of processed snacks is beneficial for overall health.

Choice E Reason:

Sugary drinks, including sodas, fruit juices with added sugars, and energy drinks, are high in calories and can lead to weight gain and increased risk of type 2 diabetes. Limiting sugary drinks is crucial for maintaining a healthy weight and preventing chronic diseases.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is confirming with the client the informed consent signed earlier that day. The client then states, “I have changed my mind and do not want to have the procedure done.” What action should the nurse take?

Correct Answer is B

Explanation

The nurse is providing education to a client about nutrition. Which foods should the client be instructed to limit in their diet? (Select all that apply)

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an abdominal wound. The nurse should understand that the JP drain was placed for which purpose?

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?

A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?

A nurse is caring for a client with numerous episodes of watery diarrhea. The client reports eating some spoiled deli meat earlier in the day. The client asks if they should take loperamide (Imodium) to stop the diarrhea. What would be an appropriate response from the nurse?

Which clinical manifestation is most reflective of an early response to hypoxia?

A nurse is assessing a client’s peripheral IV during hourly rounding. The nurse notices the site has erythema, warmth, edema, and a red line traveling up the vessel. Which complication would the nurse identify this client has?

A nurse is teaching a client who is obese and has obstructive sleep apnea on how to decrease the number of nightly apneic episodes. Which client statement indicates an understanding of the teaching?

A nurse is caring for a client diagnosed with end-stage liver cancer. Which response is an indication the client is in the denial phase of the grief process?