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. Severe vomiting can lead to a loss of gastric acid, resulting in metabolic alkalosis and not acidosis.
B. A client who is experiencing severe nausea and vomiting may lose gastric acid through vomitus and develop metabolic alkalosis, which is a condition characterized by a high pH (greater than 7.45) and a high bicarbonate (greater than 26 mEq/L). Metabolic alkalosis can cause confusion, tremors, tetany, and hypokalemia.
C. Respiratory alkalosis is not typically associated with vomiting; it is more often seen in conditions with hyperventilation.
D. Respiratory acidosis is not the primary acid-base imbalance associated with vomiting; it is more commonly associated with conditions affecting lung function.
Correct Answer is D
Explanation
A: End-stage renal failure is associated with fluid retention, making this client less likely to be at risk for fluid volume deficit.
B: Left-sided heart failure with an elevated BNP level suggests fluid overload, not deficit.
C: The client who has been NPO since midnight for endoscopy is not at risk for fluid volume deficit because the duration of fasting is not long enough to cause significant dehydration.
D: The client who has gastroenteritis and is febrile is at risk for fluid volume deficit because of the loss of fluids and electrolytes from vomiting and diarrhea, as well as the increased insensible water loss from fever.
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