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 D
Explanation
Choice A Reason:
Macular degeneration primarily affects central vision and is characterized by a gradual loss of vision rather than sudden symptoms. It does not typically cause flashes of light, shadows over the visual field, or floaters. These symptoms are more indicative of a retinal issue.
Choice B Reason:
Cataracts cause clouding of the lens, leading to blurred vision and difficulty seeing at night. However, they do not cause sudden flashes of light, shadows over the visual field, or floaters. Cataracts develop gradually and do not present with acute symptoms.
Choice C Reason:
Glaucoma is associated with increased intraocular pressure, which can lead to gradual loss of peripheral vision. While acute angle-closure glaucoma can cause sudden symptoms, it typically presents with severe eye pain, headache, and nausea, rather than flashes of light and floaters.
Choice D Reason:
Retinal detachment is characterized by the sudden onset of flashes of light, floaters, and a shadow or curtain over the visual field. These symptoms occur because the retina is pulling away from its normal position, which can lead to vision loss if not treated promptly. Immediate medical attention is required to prevent permanent vision loss.
Correct Answer is B
Explanation
Choice A Reason:
Caffeine-rich beverages are not recommended for patients with Meniere’s disease. Caffeine can exacerbate symptoms such as vertigo and tinnitus by increasing the fluid pressure in the inner ear. Therefore, avoiding caffeine is generally advised to help manage the condition.
Choice B Reason:
A low-sodium diet is an appropriate treatment for Meniere’s disease. Reducing sodium intake helps decrease fluid retention in the body, including the inner ear, which can alleviate symptoms such as vertigo, tinnitus, and hearing loss. This dietary modification is a cornerstone of managing Meniere’s disease and can significantly improve the patient’s quality of life.
Choice C Reason:
High-intensity interval training (HIIT) is not suitable for patients with Meniere’s disease. Intense physical activity can trigger vertigo attacks and worsen balance issues. Patients are generally advised to engage in moderate, low-impact exercises that do not provoke symptoms.
Choice D Reason:
Prolonged bed rest is not an appropriate treatment for Meniere’s disease. While rest may be necessary during acute vertigo attacks, long-term bed rest can lead to deconditioning and other health issues. It is important for patients to maintain a balance between rest and activity to manage their symptoms effectively.
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