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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Hepatitis C is not spread through inhalation. It is a bloodborne virus that is most commonly spread through direct contact with the blood of an infected person.
Choice B rationale
While it is possible for hepatitis C to be spread through semen, this is less common. The risk is higher for men who have sex with men, especially if they are also infected with HIV6.
Choice C rationale
Hepatitis C is not spread through feces. It is a bloodborne virus that is most commonly spread through direct contact with the blood of an infected person.
Choice D rationale
Hepatitis C is primarily spread through blood. This can occur through sharing needles, syringes, or other equipment to inject drugs, or through needle-stick injuries among healthcare workers.
Correct Answer is B
Explanation
Choice A rationale
Laying down 30 minutes after eating can actually worsen GERD symptoms. This is because the position can make it easier for stomach acid to back up into the esophagus.
Choice B rationale
Practicing good oral hygiene is important for everyone, but it doesn’t directly prevent GERD. However, it can help prevent complications of GERD such as tooth decay caused by stomach acid.
Choice C rationale
While moderate alcohol consumption may reduce stress, it can actually worsen GERD. Alcohol can relax the lower esophageal sphincter, allowing stomach acid to reflux into the esophagus. It can also increase stomach acid production.
Choice D rationale
Citrus foods are generally not recommended for people with GERD. They are acidic and can trigger GERD symptoms. Instead, non-citrus fruits like bananas, apples, and pears are better choices.
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