A 65-year-old patient with a history of chronic anemia is receiving a blood transfusion. Fifteen minutes into the transfusion, the patient reports feeling chills and has a temperature of 101°F (38.3°C). What is the most appropriate initial nursing action?
Stop the transfusion immediately and notify the healthcare provider.
Administer antipyretics and continue the transfusion.
Slow down the rate of the transfusion and reassess in 30 minutes.
Continue the transfusion and monitor the patient closely.
The Correct Answer is A
Choice A Reason:
Stopping the transfusion immediately and notifying the healthcare provider is the most appropriate initial action when a transfusion reaction is suspected. This action helps to prevent further complications and allows for prompt evaluation and management of the reaction. The nurse should also keep the IV line open with normal saline to maintain venous access.
Choice B Reason:
Administering antipyretics and continuing the transfusion is not appropriate. Continuing the transfusion could exacerbate the reaction and lead to more severe complications. The priority is to stop the transfusion and assess the patient before considering any further interventions.
Choice C Reason:
Slowing down the rate of the transfusion and reassessing in 30 minutes is not a safe approach. Any signs of a transfusion reaction, such as chills and fever, require immediate cessation of the transfusion. Delaying intervention could result in worsening of the patient’s condition.
Choice D Reason:
Continuing the transfusion and monitoring the patient closely is not appropriate. Immediate cessation of the transfusion is necessary to prevent further exposure to the potentially harmful blood product. Monitoring alone is insufficient without stopping the transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
The statement “If I forget to take my eye drops, I should wait until the next time they are due” is incorrect. For chronic open-angle glaucoma, it is important to take eye drops as prescribed to maintain consistent intraocular pressure control. If a dose is missed, the patient should take it as soon as they remember, unless it is almost time for the next dose. Skipping doses can lead to fluctuations in eye pressure, which can worsen the condition.
Choice B Reason:
The statement “Every two years I will need to have my vision checked by an eye doctor” is not accurate. Patients with chronic open-angle glaucoma typically need more frequent monitoring, often every 3 to 6 months, depending on the severity of the condition and the stability of their intraocular pressure. Regular check-ups are crucial for adjusting treatment and preventing vision loss.
Choice C Reason:
The statement “I should call the clinic before taking any over-the-counter medications” indicates an understanding of the teaching. Some over-the-counter medications can affect intraocular pressure or interact with glaucoma medications. Consulting with a healthcare provider before taking new medications helps ensure that they do not interfere with glaucoma management.
Choice D Reason:
The statement “When my vision improves, I will be able to stop taking the eye drops” is incorrect. Glaucoma is a chronic condition that requires ongoing treatment to manage intraocular pressure and prevent further damage to the optic nerve. Stopping medication can lead to a rapid increase in eye pressure and potential vision loss.
Correct Answer is A
Explanation
Choice A Reason:
Scleral buckling is a surgical procedure used to treat retinal detachment by indenting the wall of the eye. This technique involves placing a silicone band (buckle) around the sclera (the white part of the eye) to push the wall of the eye against the detached retina. This helps to reattach the retina and prevent further detachment. Scleral buckling is effective in treating many types of retinal detachments and is a common procedure for this condition.
Choice B Reason:
Photorefractive keratectomy (PRK) is a type of refractive surgery used to correct vision problems such as myopia, hyperopia, and astigmatism. It involves reshaping the cornea using a laser but is not used to treat retinal detachment. PRK does not involve indenting the wall of the eye or addressing issues with the retina.
Choice C Reason:
Vitrectomy is a surgical procedure that involves removing the vitreous gel from the eye to treat various eye conditions, including retinal detachment. While vitrectomy can be used to treat retinal detachment, it does not involve indenting the wall of the eye. Instead, it allows the surgeon to access the retina and perform necessary repairs.
Choice D Reason:
Intravitreal injection involves injecting medication directly into the vitreous cavity of the eye. This procedure is used to treat conditions such as macular degeneration, diabetic retinopathy, and retinal vein occlusion. It is not used to treat retinal detachment by indenting the wall of the eye.
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