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.
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Related Questions
Correct Answer is C
Explanation
A. While this act supports a patient's right to make decisions about their medical care, it doesn't grant the family the right to change the living will.
B. Changes to a living will should be discussed with the person who created it or someone legally designated to make those decisions, such as a durable power of attorney.
C. The living will is a legal document that outlines the client's wishes regarding medical treatment in specific situations.
D. This document designates someone to make healthcare decisions if the client is unable to do so but doesn't grant the authority to cancel the living will.
Correct Answer is D
Explanation
A. The drip chamber should not be filled completely with blood, as this can cause clotting and occlusion.
B. The blood should not be infused for more than 4 hr, as this increases the risk of bacterial contamination and transfusion reactions.
C. Medications are usually administered separately from blood products to avoid incompatibility.
D. The packed RBCs should be connected by Y tubing to normal saline to prevent hemolysis and maintain fluid balance. This is an expected finding because it allows the nurse to flush the line with normal saline before and after the blood transfusion, and to switch to normal saline in case of a transfusion reaction.
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