A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?
Stopping the transfusion
Covering the client with a blanket
Assessing the client's skin for a rash
Notifying the provider
The Correct Answer is A
A. Stopping the transfusion is the priority action if the client is experiencing symptoms of a transfusion reaction.
B. Covering the client with a blanket may address chills but does not address the potential serious nature of the reaction.
C. Assessing the client's skin for a rash is important but should not delay the immediate action of stopping the transfusion.
D. Notifying the provider is important, but stopping the transfusion and addressing the immediate needs of the client take precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A decrease in systolic blood pressure is not directly related to dehydration.
Dehydration is more associated with fluid balance.
B. With aging, there is a natural decline in kidney function, including a decrease in the ability to concentrate urine. This can contribute to an increased risk of dehydration.
C. An increase in saliva production is not typically associated with dehydration.
D. With aging, there is actually a decrease in the percentage of body water, making older adults more susceptible to dehydration.
Correct Answer is B
Explanation
A. The nurse should not withhold the dose without consulting the provider, especially with a low potassium level.
B. A client who is receiving diuretic therapy may lose potassium through urine and develop hypokalemia, which is a low level of potassium in the blood. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and fatigue. The normal range of serum potassium is 3.5 to 5.0 mEq/L. A serum potassium level of 3.2 mEq/L indicates mild hypokalemia and requires potassium supplementation
C. While it's important to verify lab results, the nurse should first administer the prescribed dose of KCL since the patient has mild hypokalemia.
D. This is important but it may delay the treatment of hypokalemia and increase the risk of complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.