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
Fever is not a typical symptom of osteoarthritis of the knee. Osteoarthritis is a degenerative joint disease that causes pain and stiffness, but it does not typically cause systemic symptoms like fever.
Choice B rationale
This is the correct answer. Crepitus, which is a grating or crackling sound or sensation, can be a symptom of osteoarthritis of the knee. It is caused by the rubbing of bone on bone due to the loss of protective cartilage in the joint.
Choice C rationale
Malaise, or a general feeling of discomfort or illness, is not a specific symptom of osteoarthritis of the knee. While osteoarthritis can cause discomfort and limit activity, it does not typically cause generalized malaise.
Choice D rationale
Weakness can occur in the muscles around an affected joint due to lack of use or muscle atrophy, but it is not a primary symptom of osteoarthritis of the knee

A. Implementing a bleeding precaution protocol B. Implementing a skin safety protocol C. Implementing a sodium restriction diet D. Implementing a fall risk protocol

Correct Answer is D

Explanation

Choice A rationale
While bleeding precautions are important in certain conditions, they may not be the priority for a patient with significant abdominal ascites. Ascites, the accumulation of fluid in the peritoneal cavity, is often caused by liver disease such as cirrhosis.
Choice B rationale
Skin safety protocols are important for all patients, but they may not be the priority in this case. Ascites can cause discomfort and other complications, but it does not directly cause skin problems.
Choice C rationale
A sodium restriction diet can be beneficial for patients with ascites, as it can help reduce fluid accumulation. However, this measure may not be the priority in this case.
Choice D rationale
Implementing a fall risk protocol should be prioritized. The patient’s significant abdominal ascites could affect their balance and mobility, increasing their risk of falls. Furthermore, the patient usually uses a cane for support but forgot to bring it to the hospital, further increasing their fall risk.

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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 performing an assessment on a patient who has osteoarthritis of the knee. Which of the following assessment findings should the nurse expect?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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