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 {"A":{"answers":"A,B"},"B":{"answers":"A,C"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Reported pain

Leukemia: Possible, as bone pain can occur due to marrow involvement.
Sickle Cell Anemia: Yes, common due to vaso-occlusive crises.
Hemophilia: No, hemophilia typically causes bleeding rather than pain from blood cell abnormalities.

Bleeding

Leukemia: Yes, due to thrombocytopenia.
Sickle Cell Anemia: No, bleeding is not typical in sickle cell crises.
Hemophilia: Yes, hemophilia is a bleeding disorder due to a clotting factor deficiency.

Temperature

Leukemia: Yes, fever can indicate infection due to immunosuppression.
Sickle Cell Anemia: Yes, fever can be a sign of infection during crises.
Hemophilia: No, hemophilia does not cause fever unless there is an infection.

Bruising

Leukemia: Yes, thrombocytopenia can lead to easy bruising.
Sickle Cell Anemia: No, bruising is not typical in sickle cell crises.
Hemophilia: Yes, due to a clotting factor deficiency, easy bruising is common.

WBC count

Leukemia: Yes, often elevated due to immature or abnormal white cells.
Sickle Cell Anemia: No, WBC count is usually normal unless there is an infection.
Hemophilia: No, WBC count is typically normal in hemophilia.

A. Malformed RBCs B. A deficiency in vitamin B12 C. An abundance of immature RBCS D. Destruction of RBCs

Correct Answer is D

Explanation

A. Malformed RBCs: Malformed RBCs are not caused by a transfusion reaction; they are generally a result of bone marrow abnormalities or genetic conditions.

B. A deficiency in vitamin B12: Vitamin B12 deficiency causes megaloblastic anemia, not hemolysis. It is unrelated to transfusion reactions.

C. An abundance of immature RBCs: Immature RBCs, or reticulocytes, can increase as a compensatory response to anemia but are not a direct result of a transfusion reaction. The primary issue is RBC destruction.

D. Destruction of RBCs: A hemolytic reaction occurs when the immune system attacks incompatible red blood cells, leading to their destruction.

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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

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,C"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

The nurse is caring for a patient receiving treatment for a hemolytic reaction from a mismatched blood transfusion. The nurse understands that this the incompatible blood is causing what?

Correct Answer is D

Explanation

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