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 D

Explanation

Choice A reason: While it is useful to know the patient's current pain management strategies, new onset severe back pain could indicate a serious complication such as a spinal fracture or compression, which requires immediate attention.

Choice B reason: Reassuring the patient is not appropriate without further assessment, as new onset severe pain could signify a serious issue that needs to be addressed.

Choice C reason: Suggesting a back brace may be part of the management plan, but it should not precede notifying the healthcare provider of new severe pain.

Choice D reason: Notifying the healthcare provider is the correct action because new onset severe back pain in a patient with multiple myeloma could indicate a serious condition such as a spinal fracture or compression, which requires prompt evaluation and treatment.

A. Clean the perineal area with an alcohol-based antiseptic solution daily. B. Irrigate the catheter once a shift. C. Replace the catheter every three days. D. Check the catheter tubing for kinks, twisting, and dependent loops.

Correct Answer is D

Explanation

Choice A reason: Cleaning with an alcohol-based solution is not recommended as it can be irritating and does not prevent infection.
Choice B reason: Routine irrigation of the catheter is not recommended as it can introduce infection.
Choice C reason: Replacing the catheter routinely every three days is not recommended and can increase the risk of infection.
Choice D reason: Ensuring the catheter tubing is free of kinks, twisting, and dependent loops is important to maintain urine ﬂow and prevent infection.

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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

A patient with multiple myeloma calls the home health nurse complaining of severe back pain of new onset. The appropriate response by the nurse is to do which of the following?

Correct Answer is D

Explanation

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

Correct Answer is D

Explanation

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