A nurse is caring for a client who is receiving a unit of PRBCs. The nurse suspects the client is experiencing a transfusion reaction. Which of the following actions should the nurse take first?
Infuse 0.9% sodium chloride.
Stop the transfusion.
Return the unit of blood to the blood bank
Obtain a blood sample from the client.
The Correct Answer is B
A. While administering 0.9% sodium chloride is an important step to maintain venous access and to help dilute any blood that might still be in the tubing, it is not the first action to take if a transfusion reaction is suspected. This step should occur after the transfusion is stopped and the patient’s safety is ensured.
B. The immediate priority when a transfusion reaction is suspected is to stop the transfusion immediately. This action helps to prevent further exposure to the potentially harmful blood product and mitigates the risk of worsening the reaction. Stopping the transfusion also allows for prompt medical assessment and intervention.
C. Returning the unit of blood to the blood bank is important for investigation and to determine the cause of the reaction, but it should be done after stopping the transfusion and ensuring the client’s safety. The blood bank may require the returned unit to confirm any issues with the blood product.
D. Obtaining a blood sample from the client is crucial for diagnostic purposes and to identify the cause of the reaction, but this should be done after the transfusion has been stopped. The sample may help in diagnosing the type of reaction or in managing it, but it does not address the immediate safety concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
A. Explaining the risks and benefits of the procedure is generally the responsibility of the surgeon or the healthcare provider who will perform the procedure. They are in the best position to provide detailed and specific information about the procedure, including potential complications and benefits.
B. Similar to explaining the risks and benefits, discussing alternatives is usually done by the surgeon or the provider. The nurse should ensure that the client is aware that alternatives are available and that this information has been provided by the appropriate medical professional.
C. It is the responsibility of the surgeon or the healthcare provider to obtain informed consent. However, the nurse should confirm that the consent process has been completed. This means ensuring that the consent form is signed and that the client has been properly informed. While the nurse does not obtain consent, they verify that it has been done correctly.
D. Describing the consequences of not undergoing the surgery is part of the informed consent process and is generally the responsibility of the surgeon. The nurse should ensure that this information has been communicated to the client by the appropriate provider.
E. The nurse often acts as a witness to the client’s signature on the consent form. This involves confirming that the client has signed the form voluntarily and after being fully informed. The nurse’s role in this process is to ensure the proper documentation and verification that the consent has been given.
Correct Answer is ["B","C","D"]
Explanation
A. Abdominal distension is not typically associated with hypokalemia.
B. Often described as pins and needles, this is a common symptom of hypokalemia.
C. Specifically, the appearance of a U wave is a characteristic sign of hypokalemia.
D. Potassium is essential for muscle function, so low levels can lead to weakness.
E. Peak T wave on EKG is associated with hyperkalemia, not hypokalemia.
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