A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?

Stop the transfusion immediately.

Inform the provider.

Call the lab and ask if this is really a transfusion reaction.

Obtain a urine specimen.

Answer and Explanation

The Correct Answer is A

Choice A reason: Stopping the transfusion immediately is the first and most critical action in response to signs of a possible transfusion reaction, which can be life-threatening.

Choice B reason: While informing the provider is a necessary step, it should come after stopping the transfusion to prevent further harm to the patient.

Choice C reason: Calling the lab is an appropriate action but not the first priority. The immediate concern is the patient's safety.

Choice D reason: Obtaining a urine specimen may be part of the diagnostic process for a transfusion reaction, but it is not the first action to take.

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Correct Answer is A

Explanation

Choice A reason: Evaluating the eﬀectiveness of opioid analgesics is crucial as pain management is a primary concern for patients experiencing a sickle cell crisis.

Choice B reason: Limiting the patient's intake of oral and IV ﬂuids is not recommended as hydration is important for patients with sickle cell crisis to reduce blood viscosity and improve circulation.

Choice C reason: Teaching the patient about high-protein, high-calorie foods is beneficial for long-term management but is not the immediate nursing intervention during a crisis.

Choice D reason: Encouraging ambulation may be part of recovery but is not the primary intervention during an acute sickle cell crisis due to the risk of pain exacerbation.

A. Enhance the formation of granulation tissue. B. Ensure brisk bleeding from the sites so ﬂuid volume status can be maintained. C. Ensure the return of distal pulses. D. Decrease edema formation.

Correct Answer is C

Explanation

Choice A reason: Enhancing the formation of granulation tissue is not the immediate expected outcome of an escharotomy.

Choice B reason: Ensuring brisk bleeding is not the goal; minimal bleeding is expected, and it should be controlled to maintain ﬂuid volume status.

Choice C reason: Ensuring the return of distal pulses is the expected outcome of an escharotomy, as it relieves pressure and restores circulation to the aﬀected limbs.

Choice D reason: Decreasing edema formation is a benefit of the procedure but not the primary expected outcome.

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A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing intervention is important when providing care for a patient with sickle cell crisis?

Correct Answer is A

Explanation

The nurse is preparing to assist the burn surgeon in performing an escharotomy for a patient who has full-thickness circumferential burns that resulted in compartment syndrome. The nurse understands that the expected outcome of this procedure is to:

Correct Answer is C

Explanation

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