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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason : Heart disease prevention is essential in managing pulmonary edema, especially when it is related to a cardiac condition.
Choice B reason : A healthy lifestyle, including diet and exercise, supports overall heart health and can help manage pulmonary edema.
Choice C reason : Smoking cessation is critical as smoking can exacerbate heart conditions and pulmonary edema.
Choice D reason : The goal of weight control is typically to reduce BMI, not increase it to over 35, which is considered obese.
Choice E reason : Glycemic control is important for diabetic patients to manage their condition and reduce the risk of complications, including pulmonary edema.
Correct Answer is B
Explanation
Choice A reason: Instructing the client to cut back to one or two drinks per day may not be effective for someone with cirrhosis, as any amount of alcohol can be harmful.
Choice B reason: Educating the client about the disease and the specific risks associated with alcohol consumption can provide the motivation needed to make a change.
Choice C reason: Introducing the client to other people who do not drink alcohol could provide social support, but it is not the primary step in motivating change.
Choice D reason: Telling the client that their liver has been destroyed by alcohol might be factual, but it is not a constructive approach to motivate change.
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