How it Works
Try Naxlex NCLEX-RN (Free-Trial)

The client admitted with sickle cell anemia crisis is being treated with a transfusion of 2 units of packed red blood cells (PRBC's) for a low hemoglobin. The cent demonstrating a new onset of chest pain. low back pain, tachycardia and anxiety. The nurse's immediate intervention is

A.

Stop transfusion, run normal saline.

B.

Administer morphine IV.

C.

Administer epinephrine IM

D.

Continue to monitor the infusion.

Answer and Explanation

The Correct Answer is A

A. Stop transfusion, run normal saline is correct because the client is likely experiencing an acute hemolytic transfusion reaction (AHTR), which is life-threatening. The priority is to stop the transfusion immediately and maintain IV access with normal saline to prevent further hemolysis.

B. Administer morphine IV is incorrect because pain management is important, but stopping the transfusion is the immediate priority.

C. Administer epinephrine IM is incorrect because epinephrine is used for anaphylaxis, not hemolytic reactions.

D. Continue to monitor the infusion is incorrect because the transfusion must be stopped immediately to prevent worsening hemolysis.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is C

Explanation

A. Respiratory rate 24 and bloody drainage in the NG tube

While an increased respiratory rate and bloody drainage are concerning, they may not indicate an immediate life-threatening situation compared to the other options.

B. Client is oriented to name and place but not the date

This suggests some level of confusion or altered mental status, which is important but not necessarily an immediate threat.

C. Blood pressure 40/48 and urine output of 24 mL/hour

This indicates severe hypotension and inadequate perfusion, which are signs of ongoing shock and possibly continued internal bleeding. Immediate intervention is critical.

D. Hypo-active bowel sounds and tachycardia

Hypo-active bowel sounds and tachycardia are concerning and suggestive of shock, but they are not as immediately life-threatening as severely low blood pressure and low urine output.

Correct Answer is C

Explanation

A. 63% TBSA
This value is too high based on the Rule of Nines calculation.

B. 45% TBSA
This overestimates the burn area.

C. 36% TBSA
Using the Rule of Nines, the TBSA is calculated as follows:

  • Entire right arm (anterior + posterior): 9%
  • Posterior trunk: 18%
  • Posterior right leg: 9%
  • Total TBSA = 9% + 18% + 9% = 36%

D. 27% TBSA
This underestimates the affected areas.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register