The nurse suspects the patient is having a blood transfusion reaction. What is the FIRST action the nurse should do?

Stop the transfusion

Call the blood bank to report the reaction

Administer oxygen

Call the physician

Answer and Explanation

The Correct Answer is A

A.   Stop the transfusion: The immediate priority is to halt the infusion to prevent further exposure to the offending blood product.
B.   Call the blood bank to report the reaction: This is done after the transfusion is stopped and the patient is stabilized.
C.   Administer oxygen: Oxygen administration may be required if the patient shows signs of respiratory distress but is not the immediate first action.
D.   Call the physician: Notifying the physician is important but only after stopping the transfusion and assessing the client.

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Correct Answer is B

Explanation

A. Prevents Rh antibodies in a newborn who is Rh-positive: The medication is not administered to newborns but to Rh-negative mothers.
B. Prevents the formation of Rh antibodies by a woman who is Rh-negative: Rho(D) immune globulin prevents maternal sensitization to Rh-positive fetal blood, avoiding hemolytic disease in future pregnancies.
C. Destroys Rh antibodies in a newborn who is Rh-positive: The goal is prevention in the mother, not antibody destruction in the newborn.
D. Destroys Rh antibodies in a woman who is Rh-negative: Rho(D) immune globulin does not destroy antibodies; it prevents their formation.

A. Liver Failure B. Thyroid Disorder C. Infection D. Cancer

Correct Answer is C

Explanation

A. Liver Failure: Lymph node enlargement is not a typical finding in liver failure. Common signs of liver failure include jaundice and ascites.
B. Thyroid Disorder: Thyroid disorders typically present with changes in metabolism, thyroid enlargement (goiter), or thyroid hormone imbalances rather than lymphadenopathy.
C. Infection: Painful, movable lymph nodes are commonly associated with bacterial or viral infections.
D. Cancer: Cancer-related lymphadenopathy is typically painless and associated with firm, fixed lymph nodes.

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The nurse suspects the patient is having a blood transfusion reaction. What is the FIRST action the nurse should do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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