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 C

Explanation

Ciprofloxacin is an antibiotic used to treat different types of bacterial infections, including urinary tract infections. Drinking plenty of fluids can help flush out bacteria from the urinary tract and prevent dehydration. Taking an antacid can reduce the absorption of ciprofloxacin and make it less effective.

Monitoring heart rate is not necessary unless the client has a history of cardiac problems or is taking other medications that affect the heart . Taking a laxative can cause diarrhea, which can worsen dehydration and electrolyte imbalance.

A. Instruct the client to cough as the catheter is inserted. B. Place the head of the client's bed lower than the foot. C. Cleanse the site with a hydrogen peroxide solution. D. Confirm the correct position of the line by obtaining a blood sample.

Correct Answer is D

Explanation

The nurse should plan to confirm the correct position of the line by obtaining a blood sample, as this is one of the methods to verify placement and patency of a central venous catheter. The nurse should also instruct the client to perform a Valsalva maneuver (bearing down) as the catheter is inserted, place the head of the client's bed higher than 30 degrees, and cleanse the site with an antiseptic solution such as chlorhexidine.

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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

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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