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 D

Explanation

Choice A rationale
Limiting fluid intake to 1 liter per day is not recommended for patients who have experienced an acute gout attack. Adequate hydration is important for all individuals, especially those with gout, as it can help to prevent the formation of uric acid crystals.
Choice B rationale
Taking one aspirin every day is not typically recommended for gout patients. Aspirin can actually increase uric acid levels in the blood and potentially trigger a gout attack.
Choice C rationale
Adhering to a high-purine diet is not recommended for gout patients. Foods high in purines can increase uric acid levels in the blood, potentially triggering a gout attack.

Choice D rationale
Restricting alcohol consumption is a key part of managing gout. Alcohol, especially beer, can increase uric acid levels in the blood and trigger gout attacks.

A. Investigate the client’s emotional concerns. B. Check the client’s perianal skin integrity. C. Obtain a dietary history from the client. D. Review the client’s electrolyte values.

Correct Answer is B

Explanation

Choice A rationale
While emotional concerns are important to address in a holistic care approach, they are not the initial course of action when a client is admitted due to an acute exacerbation of ulcerative colitis. Emotional concerns are usually addressed once the client’s physical condition is stabilized.
Choice B rationale
Checking the client’s perianal skin integrity is a crucial initial step when a client is admitted due to an acute exacerbation of ulcerative colitis. Ulcerative colitis can cause rectal bleeding and diarrhea, which can lead to skin breakdown in the perianal area. Therefore, assessing for skin integrity helps in early detection and management of potential skin complications.
Choice C rationale
Obtaining a dietary history from the client is important but not the initial course of action in this scenario. Dietary history is usually obtained once the client’s condition is stabilized and when planning for discharge or dietary modifications.
Choice D rationale
Reviewing the client’s electrolyte values is important in managing ulcerative colitis, but it’s not the initial course of action. Electrolyte imbalances can occur due to diarrhea and

malabsorption, which are common in ulcerative colitis. However, this is usually done after initial physical assessments and stabilization of the client.

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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 education to a patient who recently experienced an acute gout attack. Which patient statement indicates they have understood the treatment plan?

Correct Answer is D

Explanation

A nurse is attending to a client who has just been admitted due to an acute exacerbation of ulcerative colitis. What should be the nurse’s initial course of action?

Correct Answer is B

Explanation

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