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 B
Explanation
Choice A rationale
While acetaminophen can be used to relieve discomfort, it should be used with caution in patients with liver disease like cirrhosis, as it can potentially cause further liver damage.
Choice B rationale
Patients with cirrhosis, especially those with ascites, are often advised to limit their sodium intake. High-sodium foods can contribute to fluid retention and worsen ascites. Therefore, avoiding high-sodium foods such as canned soups/vegetables, processed meats, and prepackaged frozen dinners is a key part of managing cirrhosis.
Choice C rationale
While maintaining adequate nutrition is important in cirrhosis, eating three large meals per day is not typically recommended. Instead, smaller, more frequent meals are often suggested.
Choice D rationale
While physical activity is generally beneficial, patients with cirrhosis and particularly those with complications such as ascites or encephalopathy may need to modify their activity levels based on their symptoms and overall health.
Correct Answer is B
Explanation
Choice A rationale
While a hiatal hernia can cause discomfort and other symptoms, it does not directly increase the risk for stomach cancer.
Choice B rationale
A hiatal hernia might increase your risk for Gastroesophageal Reflux Disease (GERD). This is because the hernia can cause the lower esophageal sphincter to malfunction, allowing stomach acid to flow back into the esophagus, which is the main cause of GERD1.
Choice C rationale
A hiatal hernia does not directly increase the risk for lung disease. However, if the hernia is large, it could potentially cause breathing difficulties or exacerbate existing respiratory conditions.
Choice D rationale
A hiatal hernia does not increase the risk for intestinal cancer. The hernia occurs in the diaphragm, which is separate from the intestines.
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