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 A
Explanation
A. Rinsing the client's mouth helps to remove oral contaminants, ensuring that the sputum specimen is representative of the respiratory secretions.
B. Obtaining the specimen in the evening is not a specific requirement; the best time to collect the specimen is when the client has the most productive cough.
C. Saving the sputum specimen in a clean container is essential to prevent contamination. However, a sterile container is usually required.
D. Collecting the sputum specimen after a meal might induce coughing but can also contaminate the specimen with food particles.
Correct Answer is D
Explanation
A. While asking appropriate questions demonstrates that the partner is engaged and seeking understanding, it alone does not indicate that they are ready to perform the procedure independently.
B. Being able to verbalize all steps in the procedure shows that the partner has knowledge and understanding of the process. However, verbalizing alone does not confirm that they can perform the procedure accurately and safely. Practical skills and hands-on competence are crucial for readiness.
C. Attending a class provides important theoretical knowledge and information about tracheostomy care. However, attending a class by itself does not guarantee that the partner has developed the necessary skills to perform suctioning independently.
D. The ability to perform the procedure independently indicates that the partner has acquired the necessary skills and confidence to carry out suctioning safely and effectively. It shows practical proficiency, which is essential for readiness for discharge. The partner’s ability to perform suctioning without assistance demonstrates that they can handle the procedure in real-life situations.
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