A nurse is assisting with the care of a client who is receiving packed red blood cells. During the infusion, the client states, 'My heart is racing. The nurse notes that the client's face has become flushed. Which of the following actions should the nurse take first?

Obtain the client's vital signs.

Notify the charge nurse.

Stop the transfusion.

Administer prescribed diphenhydramine.

Answer and Explanation

The Correct Answer is C

A.   Obtain the client's vital signs: Although vital signs are essential, stopping the transfusion is the first priority to prevent further reaction.
B.   Notify the charge nurse: Communication is important but not the immediate action.
C.   Stop the transfusion: The first action is to stop the infusion to halt exposure to the potential allergen.
D.   Administer prescribed diphenhydramine: Medication administration is secondary to stopping the transfusion.

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Correct Answer is B

Explanation

A. Urticaria: Urticaria involves raised, itchy hives, not respiratory symptoms.
B. Allergic rhinitis: Characterized by itchy, red eyes, sneezing, and a runny nose, often triggered by seasonal allergens like pollen.
C. Eczema: Eczema involves dry, itchy skin lesions, not respiratory symptoms.
D. Contact dermatitis: Contact dermatitis results from direct skin contact with allergens or irritants, not airborne allergens.

A. Asian men B. Native American men C. Caucasian women D. African American women

Correct Answer is D

Explanation

A. Asian men: Asian populations have a lower risk compared to African American and Caucasian women.
B. Native American men: SLE is less common in Native American men than in women of other ethnic groups.
C. Caucasian women: While SLE is more common in women, African American women have a higher risk compared to Caucasian women.
D. African American women: African American women are at the highest risk for developing SLE, with more severe disease manifestations compared to other groups.

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A nurse is assisting with the care of a client who is receiving packed red blood cells. During the infusion, the client states, 'My heart is racing. The nurse notes that the client's face has become flushed. Which of the following actions should the nurse take first?

Nursing Test Bank

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