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 B
Explanation
A. A nonrebreather mask is used to deliver high-flow oxygen, not low-flow. It provides the highest concentration of oxygen compared to other types of masks, which is crucial for patients with severe hypoxemia. The high-flow oxygen helps in achieving a higher concentration of oxygen in the blood.
B. It is essential that a nonrebreather mask fits snugly over the client's face to ensure that the patient receives the maximum amount of oxygen and to prevent room air from mixing with the oxygen being delivered. A proper seal is necessary to achieve the desired level of oxygenation and to avoid oxygen leakage.
C. The reservoir bag on a nonrebreather mask should not collapse with each breath. Ideally, the bag should remain partially inflated even during inspiration. If the bag collapses completely, it indicates that the patient is not receiving enough oxygen, and the mask may not be functioning correctly.
D. A nonrebreather mask itself does not cause drying of the mucous membranes. However, high-flow oxygen can sometimes lead to dryness of the mucous membranes if not managed properly. Humidification may be required to prevent dryness, but this is not a direct effect of the mask itself.
Correct Answer is A
Explanation
A. Slow and steady bubbling in the suction control chamber is expected and indicates that the system is functioning properly. It is designed to regulate the pressure within the chest cavity by allowing excess air and fluid to escape, ensuring that the lungs can re-expand properly
B. Checking for leaks is are unnecessary as the system is functioning as expected.
C. Checking the suction control outlet is are unnecessary as the system is functioning as expected.
D. Clamping the chest tube is are unnecessary as the system is functioning as expected.
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.