A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

Stop the transfusion.

Notify the health care provider of the client s response.

Check the client s vital signs.

Document the findings.

Answer and Explanation

The Correct Answer is A

Difficulty breathing is a sign of a potential transfusion reaction. When a client reports difficulty breathing during a blood transfusion, the nurse should stop the transfusion immediately to prevent the reaction from worsening. Once the transfusion is stopped, the nurse can then assess the client's vital signs and notify the healthcare provider of the client's response. Documentation of the findings should also be completed after the client's condition has stabilized. However, stopping the transfusion takes priority over documenting the findings.

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Correct Answer is B

Explanation

. Assess your patient’s lower extremities and lungs for ﬂuid retention.

If a patient’s intake is 2500ml and her output is 1200ml from a catheter bag, and you are concerned that she may not be excreting enough urine for the amount of water she is taking in, the most appropriate next step would be to assess her lower extremities and lungs for ﬂuid retention. This can help determine if the patient is retaining water and if further intervention is necessary.

A. Electrolytes B. Oxygen C. Potassium D. Hemoglobin

Correct Answer is B

Explanation

During exercise, the heart has to work harder to pump blood and oxygen to the muscles. In patients with stable angina, there is a partial blockage of the coronary arteries, which reduces blood ﬂow and oxygen delivery to the heart muscle. This lack of oxygen to the heart muscles causes chest pain or discomfort, which subsides when the patient stops exercising and is relaxed.

Therefore, it is important for the patient with stable angina to avoid activities that trigger chest pain, take prescribed medications, and make lifestyle modifications to manage their condition.

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A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

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Correct Answer is B

Explanation

During a Cardiac Stress test, a patient complains of chest pain while running The chest pain subsides when he stops running and is relaxed. The patient is diagnosed with Stable angina and is given education by the nurse. He understands the lack of muscles is causing stable angina during exercise.

Correct Answer is B

Explanation

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