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 ["B","D","E"]

Explanation

A. Case manager may be involved in coordinating overall care, but based on the current assessment findings, there is a more immediate need for rehabilitation services.
B. A respiratory therapist can help manage the client's oxygen therapy and monitor their lung function.
C. Diabetes nurse educator is not directly relevant to the client's current condition as described.
D. The client's flaccid right upper and lower extremities with decreased muscle tone and strength indicate a need for rehabilitation and physical therapy.
E. The client's difficulty feeding themselves suggests a need for occupational therapy to address activities of daily living (ADLs) and improve independence.
F. Enterostomal therapy nurse is not indicated based on the information provided. The client's issues are primarily related to mobility and activities of daily living.

A. Research how to remove an IV catheter from the internet. B. Ask an assistive personnel (AP) to verbalize the steps for removing an IV catheter. C. Review the facility's policies and procedures manual about removing IV catheters. D. Find an article in a nursing journal that is less than 5 years old on how to remove IV catheters.

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.

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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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Explanation

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Correct Answer is C

Explanation

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