A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

Administer oxygen to the client.

Collect a urine sample.

Check the client's vital signs.

Stop the infusion.

Answer and Explanation

The Correct Answer is D

The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse should stop the infusion immediately and disconnect the blood tubing from the IV catheter to prevent further exposure to the incompatible blood.

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Correct Answer is D

Explanation

A mastectomy is a surgical removal of one or both breasts, usually done to treat breast cancer. The nurse should respect the client's autonomy and provide factual information about the procedure, its benefits and risks, and possible alternatives . The nurse should also assess the client's readiness to learn, address any concerns or fears, and offer emotional support . Telling the client to get a second opinion may imply that the nurse does not trust the surgeon or doubts the necessity of the procedure.

Telling the client that they will be cancer-free if they have the procedure may be false or misleading, as there may be residual cancer cells or recurrence after surgery. Giving the client a list of other people who had the same procedure may violate confidentiality and may not be helpful or relevant to the client's situation.

A. The amount of drainage is gradually decreasing. B. The client's abdomen becomes distended and firm. C. The client reports being extremely thirsty with a sore throat. D. The drainage is bright green in color with brown fecal material.

Correct Answer is B

Explanation

Abdominal distension and firmness indicate increased intra-abdominal pressure, which can compromise blood flow to the bowel and cause ischemia, necrosis, or perforation.

The nurse should report this finding to the provider and assess for signs of shock or peritonitis.

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A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first?

A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2 g per day. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red-orange in color. Which of the following responses should the nurse make?

A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?

A nurse is preparing to assist with the insertion of a non-tunneled central venous catheter for a client who is malnourished. Which of the following actions should the nurse plan to take?

A nurse in an emergency department is preparing a client for emergency surgery. The client's blood alcohol level is 180 mg/dL. Which of the following actions is the nurse's priority?

A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk?

A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglass cast. Which of the following findings should the nurse expect?