A nurse is caring for a client who is experiencing chills and back pain during a blood transfusion. What should be the nurse’s priority action?

Assess the client’s skin for a rash.

Notify the provider.

Cover the client with a blanket.

Stop the transfusion.

Answer and Explanation

The Correct Answer is D

Choice A rationale
While assessing the client’s skin for a rash could be part of the overall assessment of the client’s condition, it is not the priority action when a client is experiencing chills and back pain during a blood transfusion.
Choice B rationale
Notifying the provider is an important step when a client is experiencing a reaction to a blood transfusion, but it is not the first action that should be taken.
Choice C rationale

Covering the client with a blanket may provide comfort to the client, but it does not address the underlying issue of a potential transfusion reaction.
Choice D rationale
The priority action when a client is experiencing chills and back pain during a blood transfusion is to stop the transfusion. This is because these symptoms could indicate a transfusion reaction, which can be serious.

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Correct Answer is C

Explanation

Choice A rationale

Periorbital edema is not typically associated with the progression of systemic scleroderma.
Choice B rationale
Excessive salivation is not typically associated with the progression of systemic scleroderma.
Choice C rationale
Finger contractures can be expected in a client diagnosed with systemic scleroderma. As the disease progresses, it can cause tightening and hardening of the skin, which can lead to contractures.
Choice D rationale
Thinning of the skin is not typically associated with the progression of systemic scleroderma. In fact, the disease often causes the skin to thicken.

A. Take ibuprofen for eye discomfort. B. Wear dark glasses while outdoors. C. Notify the provider immediately if the operative eye itches. D. Creamy white drainage is an indication of infection.

Correct Answer is B

Explanation

Choice A rationale
Taking ibuprofen for eye discomfort after cataract surgery is not typically recommended. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding, which can be problematic after eye surgery.
Choice B rationale

Wearing dark glasses while outdoors is often recommended after cataract surgery. This is because the eyes can be sensitive to light after the procedure. Dark glasses can help to protect the eyes from bright light and reduce discomfort.
Choice C rationale
Itching in the operative eye is not typically a sign of a serious problem after cataract surgery. Some itching can be normal as the eye heals. However, severe pain, vision loss, or heavy discharge should be reported to the provider immediately.
Choice D rationale
Creamy white drainage is not an indication of infection. In fact, it could be a sign of a more serious problem, such as an eye infection. Any changes in vision, pain, redness, or discharge should be reported to the healthcare provider.

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A nurse is caring for a client who is experiencing chills and back pain during a blood transfusion. What should be the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with systemic scleroderma five years ago. The nurse plans to assess the client to document the disease’s progression. In addition to skin changes, which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse at an outpatient surgery center is providing discharge instructions to a patient and their spouse following the surgical removal of a cataract. What should the nurse include in these instructions?

Correct Answer is B

Explanation

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