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 C

Explanation

A. Folate: Folate is important for red blood cell production but does not address the Vitamin B12 deficiency seen in pernicious anemia.

B. Vitamin C: Vitamin C does not impact pernicious anemia as it is not involved in Vitamin B12 absorption.

C. Vitamin B12: Pernicious anemia occurs due to a lack of intrinsic factor, which is necessary for Vitamin B12 absorption. After a total gastrectomy, intrinsic factor is no longer produced, requiring Vitamin B12 supplementation.

D. Iron: Iron deficiency anemia is different from pernicious anemia, which specifically requires Vitamin B12 supplementation.

A. Explain the procedure to the patient’s family B. Observe the patient for bleeding C. Drape the biopsy site D. Administer an analgesic to the patient

Correct Answer is D

Explanation

A. Explain the procedure to the patient’s family: While helpful, this is not as crucial as ensuring patient comfort and pain management during the procedure itself.

B. Observe the patient for bleeding: Observing for bleeding is important post-procedure rather than beforehand.

C. Drape the biopsy site: Draping is part of the procedure setup, but pain management is more critical for patient preparation.

D. Administer an analgesic to the patient: Administering an analgesic is essential to manage pain and discomfort during a bone marrow biopsy. This ensures the patient is as comfortable as possible.

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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

A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia?

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Correct Answer is D

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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?