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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A blood pressure of 102/66 mm Hg is within the normal range and would not typically need to be reported to the provider.
Choice B rationale
Yellow-green drainage on the surgical incision could be a sign of a wound infection. Infections after surgery can lead to serious complications and should be reported to the provider immediately.
Choice C rationale
A respiratory rate of 18/min is within the normal range and would not typically need to be reported to the provider.
Choice D rationale
Straw-colored urine from an indwelling urinary catheter is normal and would not typically need to be reported to the provider.
Correct Answer is B
Explanation
Choice A rationale
Consuming a large amount of alcohol at one time can lead to liver damage and other health problems, but it does not directly cause hepatitis C infection. Hepatitis C is a viral infection that primarily spreads through contact with infected blood.
Choice B rationale
Coming into contact with infected blood, such as from a dirty needle, can indeed cause you to become infected with hepatitis C. This is one of the most common ways the virus is transmitted, particularly through sharing needles or other equipment to inject drugs.
Choice C rationale
Hepatitis C does not typically spread through contact with an infected person’s bodily fluids such as saliva. The virus is primarily bloodborne, meaning it spreads through direct contact with infected blood.
Choice D rationale
Eating contaminated food or water from an infected source does not cause hepatitis C. The virus does not spread through food or water, or by casual contact.
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