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 C
Explanation
A. While researching information is valuable, using the facility's policies and procedures is the best source for specific, evidence-based guidelines.
B. An AP may not be qualified to provide accurate information on removing an IV catheter.
C. The facility's policies and procedures manual is a reliable source of evidence-based guidelines for nursing care.
D. While journal articles can provide information, the facility's policies and procedures manual is often more immediately relevant and specific.
Correct Answer is A
Explanation
A. The nurse is organizing team members to ensure the comprehensive needs of the client are met.
B. A researcher focuses on gathering and analyzing data to contribute to evidence- based practice.
C. An educator provides information and teaching to clients, families, and other healthcare professionals.
D. A counselor offers emotional support and guidance to clients and their families.
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