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
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.
Correct Answer is A
Explanation
Choice A rationale
Diabetes mellitus is a risk factor for urinary tract infections (UTIs). High blood sugar levels can impair the immune system, making it harder for the body to fight off infections. Additionally, diabetes can cause nerve damage that affects the bladder’s ability to empty completely, allowing bacteria to grow.
Choice B rationale
Anemia itself is not a direct risk factor for UTIs. Anemia is a condition characterized by a lack of healthy red blood cells or hemoglobin, which does not contribute to the development of UTIs.
Choice C rationale
Chronic Obstructive Pulmonary Disease (COPD) primarily affects the lungs and does not increase the risk of UTIs. COPD can make it harder to breathe, but it does not have a direct impact on the urinary system.
Choice D rationale
Osteoporosis is a condition that weakens bones, making them fragile and more likely to break. It does not increase the risk of UTIs. Osteoporosis and UTIs are not directly related as they affect different systems within the body.
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