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 ["0.8"]
Explanation
(desired dose / available dose) x available quantity.
For this scenario, it would be (100 mg / 250 mg) x 2 mL, which equals 0.8 mL.
Therefore, the nurse should administer 0.8 mL of hydrocortisone per dose to deliver the prescribed 100 mg dosage.
Correct Answer is A
Explanation
A. Alcohol can affect blood clotting mechanisms and increase the risk of bleeding. Chronic alcohol consumption is associated with liver dysfunction, which impairs the production of clotting factors, leading to an increased risk of bleeding during and after surgery.
B. Alcohol consumption does not decrease the risk of postoperative infection. In fact, alcohol use, especially if it’s chronic, can impair the immune system and delay wound healing, potentially increasing the risk of postoperative infections.
C. Alcohol does not enhance the effectiveness of anesthesia; rather, it can complicate anesthesia management. Alcohol can interact with anesthetic agents, potentially altering their effects, leading to unpredictable outcomes.
D. Alcohol does not reduce the risk of postoperative nausea and vomiting (PONV). In fact, alcohol use can exacerbate nausea and vomiting, particularly when combined with anesthetic agents.
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