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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Hyperkalemia is a common electrolyte imbalance in prerenal AKI due to decreased kidney function and the inability to excrete potassium.

Choice B reason: Hypernatremia is not typically expected in prerenal AKI unless there is an associated condition causing increased sodium retention.

Choice C reason: Hypercalcemia is not commonly associated with prerenal AKI.

Choice D reason: Hypophosphatemia is less likely in prerenal AKI; hyperphosphatemia is more common due to decreased filtration of phosphate.

A. Disturbed body image B. Anxiety C. Ineﬀective protection D. Imbalanced nutrition: less than body requirements

Correct Answer is C

Explanation

Choice A reason: While disturbed body image is a concern, it is not the highest priority for a patient undergoing a bone marrow transplant.

Choice B reason: Anxiety is important to address but does not take precedence over physical health concerns in the immediate post-transplant period.

Choice C reason: Ineﬀective protection is the highest priority because patients undergoing bone marrow transplants have compromised immune systems and are at high risk for infection.

Choice D reason: Imbalanced nutrition is a concern but is secondary to the risk of infection in the immediate care of a patient post bone marrow transplant.

View Question and Answer

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

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 nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

Correct Answer is A

Explanation

Which of the following nursing diagnoses (nursing problem) would be of highest priority for the patient hospitalized for a bone marrow transplant to treat relapse of acute myelocytic leukemia?

Correct Answer is C

Explanation

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Which of the following are the main types of functional headaches? Select all that apply.

A client in the PACU with a left below-the-knee amputation complains of pain in her left big toe. Which of the following would the nurse do first?

Which action should the nurse take first when a patient is seen in the outpatient clinic with neck pain?

Vasoconstriction, sodium retention, and water reabsorption to increase circulating ﬂuid volume and cardiac output are the primary functions of:

A nurse is caring for a client who has cirrhosis of the liver and is having difficulty eliminating alcohol consumption because many of their friends drink alcohol socially. Which of the following steps should the nurse include to motivate the client to change?