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 C

Explanation

A. Hypokalemia causes constipation and not diarrhea.
B. Hypertensive crisis is not typically associated with hypokalemia but may be a side effect of certain antihypertensive medications.
C. Hypokalemia can affect the function of the muscles, including the respiratory muscles, leading to shallow respirations, weakness, and paralysis.
D. Hyperreflexia is not a typical manifestation of hypokalemia; it is more associated with hyperkalemia.

A. Urine specific gravity 1.020 B. Sodium 165 mEq/L C. Hct 62% D. Potassium 5.2 mEq/L

Correct Answer is A

Explanation

A. A urine specific gravity of 1.020 indicates a concentration within the normal range, suggesting that the kidneys are effectively conserving water and concentrating urine, which is a positive response to fluid therapy.
B. A sodium level of 165 mEq/L is elevated and may indicate hypernatremia, which could be a sign of inadequate water intake or excess sodium.
C. Hct (hematocrit) of 62% may indicate hemoconcentration and is not a specific marker for fluid status.
D. A potassium level of 5.2 mEq/L is within the normal range and is not a specific indicator of the effectiveness of fluid resuscitation.

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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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