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: Respiratory Acidosis is characterized by a low pH and a high PCO2, which is not the case here.
Choice B reason: Respiratory Alkalosis would involve a high pH and a low PCO2, which is not consistent with the patient's PCO2 level.
Choice C reason: Metabolic Alkalosis is indicated by a high pH and a high HCO3, which matches the patient's blood gas values.
Choice D reason: Metabolic Acidosis would show a low pH and a low HCO3, which is the opposite of this patient's presentation.
Correct Answer is B
Explanation
Choice A reason: Screening for metastasis is not typically necessary for BCC because it rarely metastasizes.
Choice B reason: Minimizing sun exposure is crucial in reducing the risk for future BCC, as UV radiation is a significant risk factor.
Choice C reason: Watchful waiting is not a standard treatment plan for BCC; treatment usually involves removal of the lesion.
Choice D reason: Low-dose systemic chemotherapy is generally not used to treat BCC; local treatments such as surgery or topical medications are preferred.
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