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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Hyperactive bowel sounds are associated with hyperkalemia, not hypokalemia.
B. Hypertension is not typically associated with hypokalemia. In fact, hypokalemia is more likely to be associated with hypotension.
C. Cerebral edema is not a common manifestation of hypokalemia; it is more commonly associated with conditions like hyponatremia.
D. Muscle weakness is a classic manifestation of hypokalemia. Potassium is crucial for proper muscle function, and a deficiency can lead to weakness.

A. Dry, sticky mucous membranes B. Muscle tremors C. Polyuria D. Negative Chvostek's sign

Correct Answer is B

Explanation

A. Dry, sticky mucous membranes are associated with dehydration, not low calcium levels.
B. Muscle tremors are a potential manifestation of hypocalcemia.
C. Polyuria is not typically associated with low calcium levels.
D. Chvostek's sign is a facial twitching that can be associated with hypocalcemia; a negative Chvostek's sign would not be expected in this case.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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