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
Donating blood after completing the medication regimen is not typically recommended for patients with hepatitis B. Hepatitis B is a bloodborne virus, and individuals with the virus should not donate blood.
Choice B rationale
Resting frequently throughout the day is a key part of self-management for patients with hepatitis B. Rest can help the body recover and fight off the virus.
Choice C rationale
Taking acetaminophen every 4 hours for discomfort is not typically recommended for patients with hepatitis B. Overuse of acetaminophen can lead to liver damage, which can be particularly harmful for individuals with liver diseases like hepatitis B56.
Choice D rationale
Consuming a high-protein diet is not typically recommended for patients with hepatitis B. A balanced diet is important for overall health, but there are no specific dietary recommendations for hepatitis B56.
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
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