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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Ceasing from smoking and consuming alcohol is crucial for patients who have been treated for acute pancreatitis. Both smoking and alcohol consumption can cause further damage to the pancreas and lead to recurrent episodes of pancreatitis.
Choice B rationale
While wearing tight-fitting clothing can be uncomfortable for some individuals, it does not have a direct impact on the recovery from acute pancreatitis.
Choice C rationale
Stopping exercise is not typically recommended for patients recovering from acute pancreatitis. Regular physical activity is generally beneficial for overall health, although a healthcare provider may recommend specific types or amounts of exercise based on the individual’s condition.
Choice D rationale
While practicing good dental hygiene is important for overall health, it does not specifically relate to the treatment or prevention of acute pancreatitis.
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.
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