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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Correct Answer is A

Explanation

Choice A reason: This statement reflects denial, which is a common initial reaction in the grief process. The client is not accepting the reality of their prognosis and believes the doctor is exaggerating. Denial serves as a defense mechanism to protect the individual from the emotional impact of the diagnosis. It is a way for the client to cope with the overwhelming news by rejecting its truth.

Choice B reason: This statement reflects anger, another stage in the grief process. The client is expressing disbelief and frustration towards the doctor’s competence. Anger often follows denial and is directed towards others as a way to cope with the emotional pain. It is not indicative of denial but rather a progression in the grieving process.

Choice C reason: This statement reflects acceptance of the physical symptoms and the reality of the client’s condition. The client acknowledges their lack of energy and the impact of the illness on their daily life. This is not a sign of denial but rather an acceptance of their current state.

Choice D reason: This statement reflects acceptance and gratitude towards the doctor. The client recognizes the efforts made by the healthcare team and accepts that their time is limited. This is a sign of acceptance, the final stage in the grief process, where the individual comes to terms with their situation.

A. Encourage the patient to drink more fluids. B. Get a prescription for an antitussive agent. C. Teach effective deep breathing. D. Change the patient’s position every 2 hours.

Correct Answer is A

Explanation

Choice A reason: Encouraging the patient to drink more fluids is a primary intervention for managing thick respiratory secretions. Adequate hydration helps to thin the mucus, making it easier to expectorate. Fluids such as water, herbal teas, and clear broths are particularly effective. The normal daily fluid intake for an adult is about 2-3 liters, depending on individual needs and health conditions.

Choice B reason: Getting a prescription for an antitussive agent is not the best initial approach for managing thick respiratory secretions. Antitussive agents are used to suppress coughing, which can be counterproductive when trying to clear mucus from the respiratory tract. Instead, expectorants or mucolytics are more appropriate as they help to thin and loosen the mucus.

Choice C reason: Teaching effective deep breathing is beneficial for overall lung health and can help in mobilizing secretions. However, it is not as immediately effective as increasing fluid intake for thinning thick secretions. Deep breathing exercises can be part of a comprehensive respiratory care plan but should be combined with other interventions like hydration.

Choice D reason: Changing the patient’s position every 2 hours is a good practice for preventing complications such as pressure ulcers and promoting lung expansion. However, it is not specifically targeted at thinning thick respiratory secretions. Positional changes can aid in the drainage of secretions but are secondary to ensuring adequate hydration.

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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 A

Explanation

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Correct Answer is A

Explanation

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