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. Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy. B. Provide the patient with a heating pad alternated with a cold pack for incisional pain. C. Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate. D. Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential.

Correct Answer is C

Explanation

A. Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy. A nebulizer is typically not the initial intervention for mild post-operative pain or mild respiratory discomfort due to pain with inspiration.

B. Provide the patient with a heating pad alternated with a cold pack for incisional pain. While heat or cold therapy can help with pain, opioid pain management with encouragement to perform deep breathing exercises is more effective for post-splenectomy patients.

C. Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate. Pain management combined with encouraging deep breathing, coughing, and early ambulation helps prevent post-operative complications like atelectasis and pneumonia, which are common after abdominal surgeries.

D. Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential. This intervention might be necessary if there were signs of infection or other complications, but mild pain with inspiration on the first day post-op does not typically warrant imaging or labs.

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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

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