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.
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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Related Questions
Correct Answer is D
Explanation
A. RBC's: Red blood cells (RBCs) are not indicative of Hodgkin’s lymphoma; they are involved in oxygen transport throughout the body and are not a specific marker for any lymphoma.
B. Bence-Jones Cells: Bence-Jones proteins are light chain proteins found in the urine of patients with multiple myeloma, not Hodgkin’s lymphoma.
C. Stem Cells: Stem cells are progenitor cells that can develop into various blood cell types but are not characteristic of Hodgkin’s lymphoma specifically. Reed-Sternberg cells, not stem cells, are the hallmark of this disease.
D. Reed-Sternberg Cell: Reed-Sternberg cells are large, abnormal B cells that are characteristic of Hodgkin’s lymphoma. Their presence in lymph node tissue is a key diagnostic feature of the disease.
Correct Answer is A
Explanation
A. The spleen is the primary site for platelet destruction. In ITP, the spleen often sequesters and destroys platelets, leading to low platelet levels. Removing the spleen reduces platelet destruction and can help increase platelet counts in affected patients.
B. The spleen is at risk for infection due to the critical loss of WBCs. While infection risk increases after splenectomy, this is not the rationale for the procedure. The spleen does play a role in immune function, but splenectomy is indicated for reducing platelet destruction, not infection prevention.
C. Your spleen is making too many platelets. The spleen does not produce platelets; rather, it filters and sometimes destroys them, particularly in ITP. This choice does not accurately reflect the pathophysiology of ITP.
D. The spleen causes an overabundance of immature platelets. The spleen does not cause an increase in immature platelets. In ITP, platelets are destroyed, not overproduced.
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