The nurse assesses a patient 20 minutes after initiating a blood transfusion. The patient has itching and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What intervention will the nurse prioritize to implement first for this patient?

Notify the blood bank of the suspected transfusion reaction.

Maintain IV access with normal saline infusion.

Facilitate the transfer of the patient to the critical care unit.

Recheck identification labels and numbers.

Answer and Explanation

The Correct Answer is B

Choice A reason: Notifying the blood bank of the suspected transfusion reaction is important, but maintaining the IV access with normal saline infusion takes priority to ensure that the patient remains stable and to prevent any further complications.

Choice B reason: Maintaining IV access with normal saline infusion is the first priority. This action helps to keep the vein open, provide fluids, and flush out any remaining blood product from the IV line, reducing the risk of further reaction.

Choice C reason: Facilitating the transfer of the patient to the critical care unit may be necessary if the patient's condition worsens, but it is not the immediate first step.

Choice D reason: Rechecking identification labels and numbers is important to confirm the correct blood product was given, but it comes after ensuring the patient’s stability by maintaining IV access with saline.

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Correct Answer is A

Explanation

Choice A reason: The lab results pH 7.30, PaCO2 59, HCO3 30 indicate respiratory acidosis with partial compensation. This is a typical finding in patients with chronic obstructive pulmonary disease (COPD) due to chronic hypoventilation and CO2 retention. The elevated PaCO2 reflects respiratory acidosis, and the elevated HCO3 indicates renal compensation to maintain acid-base balance.

Choice B reason: The lab results pH 7.50, PaCO2 30, HCO3 24 indicate respiratory alkalosis. This is not typical for COPD, where respiratory acidosis is more common.

Choice C reason: The lab results pH 7.48, PaCO2 42, HCO3 29 indicate metabolic alkalosis with partial compensation, which is not consistent with the primary respiratory issues seen in COPD.

Choice D reason: The lab results pH 7.33, PaCO2 34, HCO3 18 indicate metabolic acidosis with partial compensation, which is not typical for COPD. COPD primarily causes respiratory acidosis due to CO2 retention.

A. Kussmaul breathing B. Abdominal pain C. Positive Trousseau sign D. Decreased heart rate E. Confusion

Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Kussmaul breathing is a deep, labored breathing pattern that is a compensatory mechanism for metabolic acidosis, commonly seen in diabetic ketoacidosis.

Choice B reason: Abdominal pain is a common symptom in diabetic ketoacidosis due to the metabolic disturbances and dehydration.

Choice C reason: A positive Trousseau sign is associated with hypocalcemia and is not a common manifestation of diabetic ketoacidosis.

Choice D reason: Decreased heart rate is not typical in diabetic ketoacidosis. In fact, patients might present with an increased heart rate due to dehydration and acidosis.

Choice E reason: Confusion is a symptom of diabetic ketoacidosis due to the effects of severe hyperglycemia and metabolic acidosis on the brain.

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The nurse assesses a patient 20 minutes after initiating a blood transfusion. The patient has itching and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What intervention will the nurse prioritize to implement first for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient diagnosed with chronic obstructive pulmonary disease (COPD). Which lab results will the nurse expect to find to support this diagnosis?

Correct Answer is A

Explanation

The nurse is caring for a patient with diabetic ketoacidosis (DKA). What clinical manifestations will the nurse anticipate the patient to present? (Select All That Apply)

Correct Answer is ["A","B","E"]

Explanation

The nurse is teaching a patient with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. The patient demonstrates understanding of hypoglycemia by stating they will check their blood glucose when experiencing which of the following symptoms?

The nurse is caring for a patient receiving packed red blood cells which started at 11:30 AM. The patient's vital signs and assessment findings are provided in the table below. What type of transfusion reaction will the nurse identify that the patient is experiencing?

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The nurse is assessing a patient who is diagnosed with inflammatory bowel disease and is requiring inpatient treatment at a hospital. What medication will the nurse provide when caring for this patient?

The nurse is caring for a patient with diabetic ketoacidosis. Which assessment finding indicates to the nurse that the patient is experiencing fluid volume deficit?