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 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.
Correct Answer is C
Explanation
Choice A rationale
Telling the patient that their liver has been destroyed by alcohol might not be the most effective way to motivate change. It could potentially lead to feelings of hopelessness and deter the patient from seeking help.
Choice B rationale
Introducing the patient to other people might not directly motivate them to change their alcohol consumption habits. However, it could potentially provide them with a supportive network that could help them in their journey to sobriety.
Choice C rationale
Educating the patient about the disease can be very beneficial. Understanding the effects of alcohol on their liver and the potential consequences of continued drinking can motivate them to change.
Choice D rationale
Instructing the patient to cut back to drinking one drink per day might not be the best advice for a patient with cirrhosis of the liver. Complete abstinence from alcohol is usually recommended for these patients to prevent further liver damage.
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