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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Petroleum-based products should not be used in conjunction with oxygen therapy. They are flammable and can pose a fire hazard when used near oxygen. Instead, use water-based moisturizers to prevent dryness of the lips and skin.
B. Wool and other synthetic fabrics can generate static electricity, which is a fire hazard when using oxygen
therapy. It’s safer to use cotton blankets, as they are less likely to cause static buildup.
C. Oxygen tanks should be stored upright to prevent them from falling over and to ensure the regulator and valves are properly aligned. Storing tanks upright helps maintain stability and prevents accidental damage to the equipment.
D. While the recommendation to keep oxygen tanks away from electrical sources is important, the distance may vary based on specific guidelines. It is generally advised to keep oxygen tanks at least 5-10 feet away from electrical sources and heat sources to avoid any risk of ignition or fire.

A. Check the cannula position on a regular basis. B. Apply petroleum ointment to nares if they become dry and irritated. C. Check the tops of the ears for skin breakdown. D. Verify the oxygen flow rate every other day. E. Post "no smoking" signs in a prominent location in the home.

Correct Answer is ["A","C","E"]

Explanation

A. Checking the cannula regularly helps to to ensure proper positioning and comfort.
B. Applying petroleum ointment to nares is not recommended; use water-based products instead.
C. Checking the tops of the ears for skin breakdown helps to prevent and address potential skin issues.
D. The oxygen flow rate should be monitored according to the healthcare provider's instructions, not just every other day, to make sure the prescribed amount is being received
E. A "no smoking" signs essential for safety due to the flammability of oxygen.

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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?

Nursing Test Bank

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Explanation

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