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

Stop transfusion, run normal saline.

Administer morphine IV.

Administer epinephrine IM

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.

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Correct Answer is B

Explanation

A. Mini mental status exam at admission and discharge

Useful for cognitive function but not for acute changes.

B. Performing serial Glasgow Coma Scale exams

The GCS is the best tool for tracking changes in neurologic status over time.

C. Assessing pupils for reactivity, equality, symmetry, and accommodation

Important but not comprehensive.

D. Obtaining vital signs every four hours

Useful but does not specifically assess neurologic function.

A. inability to understand directions B. Lesion of cranial nerve IX C. Dysfunction of the cerebellum D. Vestibular disease

Correct Answer is C

Explanation

A. Inability to understand directions
The client's issue is with motor coordination, not comprehension.

B. Lesion of cranial nerve IX
Cranial nerve IX (Glossopharyngeal) is associated with swallowing and taste, not motor coordination.

C. Dysfunction of the cerebellum
The cerebellum controls coordination and fine motor movements. The client's inability to perform rapid alternating movements (dysdiadochokinesia) suggests cerebellar dysfunction.

D. Vestibular disease
Vestibular disorders cause dizziness, vertigo, and balance problems but do not typically affect rapid alternating movements.

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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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an assessment on a client. How would the nurse best evaluate improvement or deterioration in the neurologic status?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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