The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?

Remove the client's IV access.

Assess the client's chest sounds and vital signs

Notify the client's healthcare provider.

Stop the transfusion immediately.

Answer and Explanation

The Correct Answer is D

A. Remove the client's IV access:

Removing the client's IV access is not the most appropriate initial action when a client experiences difficulty breathing and severe chest tightness during a transfusion. While it's important to discontinue the infusion, the immediate priority is to stop the transfusion itself to prevent further reaction and assess the client's condition.

B. Assess the client's chest sounds and vital signs:

This choice is the correct answer. After stopping the transfusion, the nurse should assess the client's respiratory status by listening to chest sounds for any wheezing or crackles, as well as checking vital signs such as oxygen saturation, respiratory rate, blood pressure, and heart rate. These assessments help evaluate the severity of the reaction and guide further interventions.

C. Notify the client's healthcare provider:

Notifying the healthcare provider is an essential step, but it typically follows the immediate action of stopping the transfusion and assessing the client's condition. The healthcare provider needs to be informed promptly about the client's condition, transfusion reaction, and the actions taken for further guidance and orders.

D. Stop the transfusion immediately:

This is the initial and most critical action when a client experiences signs of a transfusion reaction such as difficulty breathing and severe chest tightness. Stopping the transfusion promptly helps prevent the reaction from worsening and allows for immediate assessment and intervention to ensure client safety.

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Correct Answer is D

Explanation

A. Furosemide 10mg IV bolus every 12 hours:

Furosemide is a loop diuretic commonly used in heart failure management to reduce fluid overload. The prescribed dose of 10 mg IV bolus every 12 hours is within the typical range for furosemide administration in acute heart failure.

B. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain:

Morphine sulfate is often used in the management of acute pain, including pain associated with myocardial infarction. The prescribed dose of 2 mg IV bolus every 2 hours PRN for pain is appropriate and aligns with standard pain management protocols.

C. Laboratory testing of serum potassium upon admission:

It is common practice to perform laboratory testing, including serum potassium levels, upon admission for clients with acute heart failure, especially if they are receiving diuretics or other medications that can affect electrolyte balance. This prescription is appropriate and necessary for monitoring the client's condition.

D. 0.9% normal saline IV at 150 mL/hr continuous:

This prescription raises a concern because administering 0.9% normal saline at a rate of 150 mL/hr continuously may lead to fluid overload in a client with acute heart failure. The rate of IV fluid administration should be carefully assessed based on the client's fluid status, renal function, and hemodynamic parameters to avoid exacerbating heart failure symptoms.

A. initiate cardiopulmonary resuscitation. B. Administer sublingual nitroglycerin to allow the client to finish the test. C. Stop the test and monitor the client closely. D. Administer analgesia and slow the test.

Correct Answer is C

Explanation

A. Initiate cardiopulmonary resuscitation (CPR): CPR is not indicated in this scenario unless the client experiences a cardiac arrest. Chest pain during an exercise stress test does not automatically warrant CPR.

B. Administer sublingual nitroglycerin to allow the client to finish the test: Nitroglycerin is typically used to relieve angina (chest pain) associated with myocardial ischemia. However, in this case, the exercise stress test should be stopped to evaluate the cause of the chest pain before administering nitroglycerin.

C. Stop the test and monitor the client closely: This is the correct action. Chest pain during an exercise stress test may indicate myocardial ischemia (lack of blood flow to the heart muscle), and stopping the test allows for further assessment and evaluation of the client's condition.

D. Administer analgesia and slow the test: Administering analgesia (pain medication) is not appropriate without first determining the cause of the chest pain. Slowing the test may not address the underlying issue and could potentially worsen the client's condition if they are experiencing cardiac-related chest pain.

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The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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