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 A
Explanation
Choice A Reason:
Losing weight is one of the most effective ways to reduce the severity of obstructive sleep apnea (OSA). Excess weight, especially around the neck, can increase the risk of airway obstruction during sleep. Studies have shown that losing even 5-10% of body weight can significantly improve OSA symptoms. Therefore, the statement about losing 50 pounds indicates a good understanding of how weight loss can help manage sleep apnea.
Choice B Reason:
Taking a sleeping pill at night is not recommended for individuals with obstructive sleep apnea. Many sleeping pills, especially those that are sedatives or muscle relaxants, can worsen sleep apnea by relaxing the muscles of the throat, leading to increased airway obstruction. Therefore, this statement does not indicate an understanding of the appropriate management of sleep apnea.
Choice C Reason:
Using a humidifier can help alleviate some symptoms associated with sleep apnea, such as dry mouth and nasal congestion, but it does not directly reduce the number of apneic episodes. While a humidifier can improve comfort, it is not a primary treatment for reducing apneic episodes in OSA patients.
Choice D Reason:
Sleeping on the back is generally not recommended for individuals with obstructive sleep apnea. This position can cause the tongue and soft tissues to collapse to the back of the throat, worsening airway obstruction. Side sleeping is usually recommended to help keep the airway open. Therefore, this statement does not indicate an understanding of the best sleep practices for managing sleep apnea.
Correct Answer is B
Explanation
Choice A reason: Placing a surgical mask on the client during transport is not the primary precaution for C. difficile infections. C. difficile is primarily transmitted through contact with contaminated surfaces and not through respiratory droplets. Therefore, while masks may be used for other infections, they are not the main precaution for C. difficile.
Choice B reason: Using gown and gloves when entering the room is essential for preventing the spread of C. difficile. This infection is highly contagious and can be transmitted through contact with contaminated surfaces or feces. Gown and gloves provide a barrier that helps prevent the transmission of the bacteria to healthcare workers and other patients.
Choice C reason: Using an alcohol-based agent to perform hand hygiene is not effective against C. difficile spores. Hand washing with soap and water is recommended because it is more effective at removing the spores from the hands. Alcohol-based hand sanitizers do not kill C. difficile spores and should not be relied upon for hand hygiene in this context.
Choice D reason: Obtaining a blood specimen to test for C. difficile is not the standard diagnostic method. C. difficile infections are typically diagnosed through stool tests that detect the presence of the bacteria or its toxins. Blood tests are not used for diagnosing C. difficile infections.
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