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 B

Explanation

Choice A rationale
Maintaining systolic BP between 136 and 140 mm Hg is not recommended for clients who have hypertension and have experienced a TIA789. Studies have shown that maintaining a lower systolic BP can help reduce the risk of recurrent stroke.
Choice B rationale
The client should aim to maintain systolic BP between 120 and 129 mm Hg. This range is associated with a reduced risk of recurrent stroke. Lifestyle modifications and antihypertensive therapy can help achieve this target.
Choice C rationale

Maintaining systolic BP between 141 and 145 mm Hg is not recommended for clients who have hypertension and have experienced a TIA789. This range is higher than the recommended target and may increase the risk of recurrent stroke.
Choice D rationale
Maintaining systolic BP between 130 and 135 mm Hg is not the recommended target for clients who have hypertension and have experienced a TIA789. The recommended target is lower to help reduce the risk of recurrent stroke.

A. Peptic ulcer disease B. Dumping syndrome C. Aspiration D. Gastroesophageal reflux disease

Correct Answer is C

Explanation

Choice A rationale

Peptic ulcer disease is not a common complication of difficulty swallowing after a stroke. It is typically caused by an infection with the bacterium Helicobacter pylori or long-term use of nonsteroidal anti-inflammatory drugs.
Choice B rationale
Dumping syndrome is not a common complication of difficulty swallowing after a stroke. It is a condition that can occur after surgery to remove all or part of your stomach or after surgery to bypass your stomach to help you lose weight.
Choice C rationale
Aspiration is a common problem for people with dysphagia, a condition that can occur after a stroke. It occurs when something you’ve swallowed enters the airway and lungs. Normally, aspiration causes a violent cough, but a stroke can reduce sensation. In this case, you may not know you’re aspirating (silent aspiration)5.
Choice D rationale
Gastroesophageal reflux disease (GERD) is not a common complication of difficulty swallowing after a stroke. GERD is a chronic disease that occurs when stomach acid or bile flows into the food pipe and irritates the lining.

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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 providing discharge instructions to a client who has hypertension, which has resulted in a transient ischemic attack (TIA). What information regarding blood pressure (BP) management should the nurse discuss with the client?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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