A nurse is caring for a client who is receiving a transfusion of packed red blood cells and develops itching and hives. What should be the nurse’s first response?
Obtain vital signs.
Notify the registered nurse.
Administer diphenhydramine.
Stop the transfusion.
The Correct Answer is D
Rationale for Choice A: Obtain vital signs
While obtaining vital signs is important in assessing a patient's overall condition, it is not the first priority in a suspected transfusion reaction.
Vital signs can provide valuable information about the severity of the reaction, but they should not delay the immediate action of stopping the transfusion.
Delaying the cessation of the transfusion could allow for further infusion of incompatible blood or allergens, potentially worsening the reaction and leading to more serious complications.
Rationale for Choice B: Notify the registered nurse
Involving other healthcare professionals is crucial in managing transfusion reactions, but it should not precede stopping the transfusion.
The nurse should prioritize stopping the transfusion to prevent further exposure to potential triggers and then promptly notify the registered nurse for further assessment and interventions.
Timely communication with the registered nurse is essential for coordinating care and ensuring appropriate treatment measures are implemented.
Rationale for Choice C: Administer diphenhydramine
Diphenhydramine, an antihistamine, can be used to treat allergic reactions, but it should not be administered as the first response in this scenario.
The priority is to halt the infusion of the blood product that is potentially causing the reaction.
Administering diphenhydramine before stopping the transfusion could mask the symptoms of the reaction, making it more difficult to assess its severity and progression.
Rationale for Choice D: Stop the transfusion
This is the correct and most immediate action to take when a patient develops itching and hives during a blood transfusion.
These symptoms are indicative of a possible allergic or transfusion reaction, and stopping the transfusion is essential to prevent further complications.
It's critical to act quickly to minimize the amount of incompatible blood or allergens that enter the patient's circulation.
By stopping the transfusion, the nurse can potentially prevent the reaction from worsening and safeguard the patient's well- being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Respiratory acidosis is characterized by a low pH (less than 7.35), a high PaCO2 (greater than 45 mm Hg), and a normal or high HCO3 (22-26 mEq/L). It occurs when there is a buildup of carbon dioxide in the blood due to impaired ventilation.
The patient's ABGs do not align with respiratory acidosis because the pH is elevated (7.6), and the PaCO2 is within the normal range (40 mm Hg).
Choice B rationale:
Respiratory alkalosis is characterized by a high pH (greater than 7.45), a low PaCO2 (less than 35 mm Hg), and a normal or low HCO3 (22-26 mEq/L). It occurs when there is excessive loss of carbon dioxide through hyperventilation.
The patient's ABGs do not align with respiratory alkalosis because the HCO3 is elevated (32 mEq/L), which is not typical for this condition.
Choice C rationale:
Metabolic acidosis is characterized by a low pH (less than 7.35), a normal or low PaCO2 (less than 40 mm Hg), and a low HCO3 (less than 22 mEq/L). It occurs when there is an excess of acid in the body or a loss of bicarbonate.
The patient's ABGs do not align with metabolic acidosis because the pH is elevated (7.6), and the HCO3 is elevated (32 mEq/L).
Choice D rationale:
Metabolic alkalosis is characterized by a high pH (greater than 7.45), a normal or high PaCO2 (40-45 mm Hg), and an elevated HCO3 (greater than 26 mEq/L). It occurs when there is an excess of bicarbonate in the body or a loss of acid.
The patient's ABGs align with metabolic alkalosis because of the high pH (7.6), normal PaCO2 (40 mm Hg), and elevated HCO3 (32 mEq/L).
Correct Answer is B
Explanation
Choice A rationale:
While explaining the importance and rationale of the new policy can be helpful, it may not address the underlying reasons for the nurse's resistance.
If the nurse does not understand or agree with the rationale, they may still be resistant to change.
Additionally, simply providing information may not create an open and trusting environment where the nurse feels comfortable expressing their concerns.
Choice B rationale:
Encouraging the nurse to verbalize their concerns allows the nurse manager to understand the specific reasons for the resistance.
This can help to identify any misconceptions or concerns that can be addressed directly.
It also gives the nurse an opportunity to feel heard and understood, which can help to build trust and rapport. When nurses feel that their concerns are being taken seriously, they are more likely to be open to change.
Choice C rationale:
Threatening disciplinary action is likely to create resentment and further resistance. It may also damage the relationship between the nurse manager and the nurse.
This approach should only be used as a last resort, after other attempts to address the resistance have failed.
Choice D rationale:
Ignoring the resistance is not an effective strategy.
It is likely to lead to continued noncompliance with the new policy,
It may also send the message that the nurse manager does not care about the nurse's concerns.
Peer pressure can sometimes be helpful in facilitating change, but it should not be relied upon as the sole strategy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.