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 C
Explanation
Choice A reason: The recovery position is not typically recommended for patients with acute pulmonary edema as it does not facilitate optimal breathing.
Choice B reason: The prone position is not generally recommended for acute pulmonary edema as it may not aid in improving oxygenation or breathing.
Choice C reason: The sitting up position, especially at an angle of 45 degrees or greater, is recommended for patients with acute pulmonary edema as it helps to facilitate breathing and decrease venous return to the heart.
Choice D reason: The Trendelenburg position is not recommended for acute pulmonary edema as it can increase the pressure in the chest and worsen breathing difficulties.
Correct Answer is B
Explanation
Choice A reason: Dumping syndrome is not commonly associated with dysphagia post-stroke.
Choice B reason: Aspiration is a significant risk for patients with dysphagia following a stroke and should be closely monitored to prevent complications like aspiration pneumonia.
Choice C reason: Gastroesophageal reflux disease may occur but is not the most immediate concern for stroke patients with dysphagia.
Choice D reason: Peptic ulcer disease is not directly related to dysphagia and is less likely to be an immediate complication post-stroke.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.