A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?

Stop the transfusion.

Administer diphenhydramine.

Obtain vital signs.

Notify the registered nurse.

Answer and Explanation

The Correct Answer is A

A. Stop the transfusion: Stopping the transfusion is the priority action to prevent further exposure to the antigen causing the reaction.

B. Administer diphenhydramine: Administering diphenhydramine is an appropriate intervention for allergic reactions, but stopping the transfusion should be done first to halt the reaction source.

C. Obtain vital signs. Obtaining vital signs is important but should follow stopping the transfusion to address the immediate risk of reaction.

D. Notify the registered nurse: Notifying the registered nurse is necessary but comes after stopping the transfusion to immediately mitigate the reaction.

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Correct Answer is D

Explanation

A. Have the child eat a high-protein diet. There is no specific requirement for a high-protein diet to manage sickle cell disease. Hydration is more critical in crisis prevention.

B. Monitor the child's temperature twice per day. While monitoring for infection is essential, this is not the most important discharge instruction to prevent crises.

C. Restrict outdoor play activity. While strenuous exercise should be avoided, activity restriction is unnecessary as long as the child stays hydrated and avoids extreme conditions.

D. Encourage the child to increase his fluid intake. Increased fluid intake helps prevent sickling by reducing blood viscosity, which is essential in preventing future crises.

A. Ineffective airway clearance related to swelling of the lymph nodes B. Ineffective tissue perfusion related to vascular occlusion C. Risk for injury related to compromised bone integrity D. Risk for deficit fluid volume related to a bleeding disorder

Correct Answer is C

Explanation

A. Ineffective airway clearance related to swelling of the lymph nodes: Multiple myeloma primarily affects bone marrow and bones rather than lymph nodes, so this diagnosis is less relevant.

B. Ineffective tissue perfusion related to vascular occlusion: Vascular occlusion is not a common complication of multiple myeloma, although hyperviscosity can occur, especially in advanced stages. However, the primary concern is bone integrity.

C. Risk for injury related to compromised bone integrity: Multiple myeloma weakens bones due to the presence of osteolytic lesions, increasing the risk for fractures. Teaching the family about measures to prevent injury is crucial.

D. Risk for deficit fluid volume related to a bleeding disorder: Multiple myeloma does not usually cause a primary bleeding disorder that would result in fluid volume deficit. Bone fractures and hypercalcemia are more immediate concerns.

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A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

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