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
The effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis can be evaluated by observing the patient’s stool. Pancreatic enzyme replacement therapy (PERT) is used to improve digestion and absorption of nutrients in patients with pancreatic insufficiency, a common complication of chronic pancreatitis. One of the primary goals of PERT is to reduce steatorrhea, or fatty stools, which is a common symptom of pancreatic insufficiency. Therefore, observing changes in the patient’s stool, such as a reduction in fat content, can help evaluate the effectiveness of PERT567.
Choice B rationale
While saliva plays a role in the initial stages of digestion, it is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in saliva are not indicative of the effectiveness of this therapy.
Choice C rationale
Nasal mucus is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in nasal mucus are not indicative of the effectiveness of this therapy.
Choice D rationale
Urine is not typically used to evaluate the effectiveness of pancreatic enzyme replacement therapy in patients with chronic pancreatitis. PERT is primarily aimed at improving the digestion and absorption of nutrients in the intestines, and changes in urine are not indicative of the effectiveness of this therapy.
Correct Answer is A
Explanation
Choice A rationale
Hepatitis A is primarily transmitted through fecal contamination of food or water. This can occur when an infected person does not wash their hands properly after going to the bathroom and then touches food or other objects that others then put in their mouths.
Choice B rationale
While sexual intercourse can potentially transmit Hepatitis A, it is not the primary mode of transmission. The risk is higher if the sexual activity involves oral-anal contact.
Choice C rationale
Kissing mouth-to-mouth is not typically a primary mode of Hepatitis A transmission unless fecal particles are somehow involved.
Choice D rationale
Contact with infected blood is not the primary mode of Hepatitis A transmission. Hepatitis A is primarily spread through the fecal-oral route, not through blood.
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