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 B
Explanation
Choice A reason: Inadequate retention of serum sodium is not typically associated with anemia in chronic renal failure.
Choice B reason: Inadequate production of erythropoietin is the correct answer because the kidneys produce erythropoietin, which stimulates the bone marrow to produce red blood cells. In chronic renal failure, the kidneys cannot produce enough erythropoietin, leading to anemia.
Choice C reason: While blood loss in the urine can occur, it is not the primary cause of anemia in chronic renal failure.
Choice D reason: Renal desensitization to Vitamin D affects bone health and calcium levels but is not the primary cause of anemia in chronic renal failure.
Correct Answer is B
Explanation
Choice A reason: A PR interval of 0.04-0.20 seconds is too broad and includes values that are both below and above the normal range.
Choice B reason: A PR interval of 0.12-0.20 seconds is the established normal range for adults, reflecting proper conduction through the AV node.
Choice C reason: The PR interval being less than half the R-to-R ratio is not a standard measurement for PR intervals and does not provide a specific range.
Choice D reason: A PR interval of 0.08-0.10 seconds is below the normal range and may suggest pre-excitation or an AV nodal (junctional) rhythm.
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