A nurse is caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss.
The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse’s first action?

Stop the infusion of blood.

Notify the laboratory.

Obtain a urine specimen.

Inform the provider.

Answer and Explanation

The Correct Answer is A

Choice A rationale
If a client reports chills and back pain during a blood transfusion, and their blood pressure is 80/64 mm Hg, the nurse’s first action should be to stop the infusion of blood. These symptoms could indicate an acute intravascular hemolytic transfusion reaction, and the greatest risk to the client is injury from receiving additional blood.

Choice B rationale
Notifying the laboratory is an important step in managing a transfusion reaction, but it is not the first action that should be taken.
Choice C rationale
Obtaining a urine specimen could be part of the overall assessment of the client’s condition, but it is not the first action that should be taken when a client is experiencing a potential transfusion reaction.
Choice D rationale
Informing the provider is an important step when a client is experiencing a reaction to a blood transfusion, but it is not the first action that should be taken.

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Correct Answer is A

Explanation

Choice A rationale
Sleep problems are a common non-gastrointestinal symptom associated with IBS345. These can include difficulty falling asleep, frequent awakenings during the night, and feeling unrefreshed upon waking.
Choice B rationale
General muscle aches are not typically associated with IBS. While some people with IBS may experience discomfort or pain in various parts of their body, these symptoms are not usually described as muscle aches.
Choice C rationale
Paresthesias, or abnormal sensations such as tingling or prickling, are not typically associated with IBS345.
Choice D rationale
Restlessness is not typically associated with IBS. However, some people with IBS may experience increased anxiety or stress, which could potentially lead to feelings of restlessness.

A. Nonfat milk B. Chocolate C. Oatmeal D. Apples

Correct Answer is B

Explanation

Choice A rationale
Nonfat milk is generally not a trigger for GERD101112131415. It is low in fat and thus less likely to relax the lower esophageal sphincter, which can lead to acid reflux1415.
Choice B rationale

Chocolate is known to trigger GERD symptoms1415. It contains caffeine and fat, which can relax the lower esophageal sphincter and cause acid reflux1415.
Choice C rationale
Oatmeal is generally not a trigger for GERD101112131415. It is a whole grain that is high in fiber, which can help control GERD symptoms1415.
Choice D rationale
Apples are generally not a trigger for GERD101112131415. They are non-citrus fruits and thus less likely to cause acid reflux1415.

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A nurse is caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss. The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse’s first action?

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A nurse is caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss.
The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse’s first action?