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. 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.

A. Intense abdominal pain B. Respiratory depression C. Dyspnea on exertion D. Bradycardia

Correct Answer is C

Explanation

A. Intense abdominal pain: While abdominal pain may occur in some conditions related to anemia, it is not a typical finding in anemia due to blood loss.

B. Respiratory depression: Respiratory depression is not commonly associated with anemia and would more likely indicate issues with central nervous system depression or drug side effects.

C. Dyspnea on exertion: Dyspnea on exertion is common in clients with anemia because of the decreased oxygen-carrying capacity of the blood, leading to tissue hypoxia. Anemia results in decreased hemoglobin levels, reducing the body’s ability to deliver adequate oxygen, particularly during physical activity.

D. Bradycardia: Anemia typically causes tachycardia (increased heart rate) rather than bradycardia, as the body compensates for low oxygen levels by increasing cardiac output.

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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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