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 B

Explanation

A chest physiotherapy vest is a device that delivers high-frequency chest wall oscillation to loosen and mobilize mucus from the airways . This helps improve lung function and prevent respiratory infections in patients with cystic fibrosis, who have thick and sticky mucus production . A peak flow meter is used to measure the peak expiratory flow rate, which reflects the degree of airway obstruction in patients with asthma .

An NG tube with suction apparatus is used to decompress the stomach and remove gastric contents in patients with bowel obstruction, paralytic ileus, or gastroparesis . A chest tube with a drainage system is used to remove air or fluid from the pleural space in patients with pneumothorax, hemothorax, or pleural effusion .

A. Recommend staying at a local shelter until the client can afford the bill. B. Contact the local Department of Health and Human Services for the client. C. Contact the client's family members to tell them the client's financial status. D. Provide the client with written information about the dangers of hypothermia.

Correct Answer is B

Explanation

This is because older adults are at increased risk of hypothermia, which is a potentially life-threatening condition that occurs when the body temperature drops below 35° C (95° F).

Hypothermia can cause confusion, drowsiness, slurred speech, slow heartbeat, shallow breathing, and loss of consciousness. Some factors that increase the risk of hypothermia in older adults are low indoor temperature, inadequate clothing, poor nutrition, chronic illness, medication use, and social isolation.

The nurse should contact the local Department of Health and Human Services for the client to help them access resources and programs that can assist them with paying their heating bills or finding alternative housing options. The nurse should also educate the client on how to prevent hypothermia by wearing warm clothing, eating well-balanced meals, drinking warm fluids, avoiding alcohol and caffeine, and staying active.

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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 B

Explanation

Correct Answer is B

Explanation

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