A nurse is administering Packed Red Blood Cells (PRBC) to a client who reports having lower back pain and feeling chilled and itchy.
Which of the following actions should the nurse take first?

Return the platelet bag and tubing to the blood bank.

Stop the infusion.

Notify the provider.

Collect a urine sample from the client.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Returning the platelet bag and tubing to the blood bank is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which is a serious complication that requires immediate intervention.

Choice B rationale

Stopping the infusion is the first action the nurse should take when a client reports symptoms of a transfusion reaction. This is because continuing the transfusion could worsen the reaction and potentially lead to more serious complications.

Choice C rationale

While notifying the provider is an important step in managing a transfusion reaction, it is not the first action the nurse should take. The nurse should first stop the infusion to prevent further exposure to the blood product.

Choice D rationale

Collecting a urine sample from the client is not the immediate action to take when a client reports having lower back pain and feeling chilled and itchy during a PRBC transfusion. These symptoms could indicate a transfusion reaction, which requires immediate intervention.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale

The task of recording strict nutritional content is within the scope of practice for an assistive personnel (AP). The AP can keep track of the client’s food and fluid intake and report this information to the nurse. This is important in this case as the client has not been eating and the provider has prescribed a regular tray with finger foods at each meal. The nurse can then use this information to assess the client’s nutritional status and make necessary adjustments to the care plan.

Choice B rationale

Administering medication, such as memantine, is not within the scope of practice for an AP. This task requires knowledge and skills related to pharmacology, assessment, and evaluation that are beyond the training of an AP. Therefore, this task should be performed by a licensed nurse.

Choice C rationale

Performing neurological checks is also not within the scope of practice for an AP. These checks involve assessing the client’s level of consciousness, orientation, and neurological function, which require advanced assessment skills. Therefore, this task should be performed by a licensed nurse.

Choice D rationale

Continuing the bowel training program could potentially be within the scope of practice for an AP, depending on the specific tasks involved. However, in this case, the family member has reported that the client is having more difficulty staying focused, which suggests that the bowel training program may need to be adjusted. This requires nursing judgment and therefore should be performed by a licensed nurse.

A. “Taking the medication between meals will help you absorb the medication more efficiently.”. B. “The medication can cause nausea if taken with food.”. C. “Taking the medication with food increases the risk of esophagitis.”. D. “Taking the medication between meals will help you avoid becoming constipated.”.

Correct Answer is A

Explanation

Choice A rationale

Taking ferrous sulfate between meals can help increase absorption of the medication. Iron is best absorbed on an empty stomach. However, it may need to be taken with food to reduce stomach upset.

Choice B rationale

While it’s true that ferrous sulfate can cause nausea, this is not the primary reason for taking it between meals. The main goal is to enhance absorption.

Choice C rationale

There’s no evidence to suggest that taking ferrous sulfate with food increases the risk of esophagitis.

Choice D rationale

While constipation can be a side effect of ferrous sulfate, taking it between meals does not necessarily prevent this.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is administering Packed Red Blood Cells (PRBC) to a client who reports having lower back pain and feeling chilled and itchy.Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has moderate Alzheimer's disease. Exhibits To effectively manage the provider prescriptions, which of the following tasks should the nurse assign to an assistive personnel (AP)?

Correct Answer is A

Explanation

A nurse is caring for a client who has a new prescription for ferrous sulfate tablets twice daily for iron-deficiency anemia.The client asks the nurse why the provider instructed that she take the ferrous sulfate between meals.Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a patient who has an active upper gastrointestinal bleed.After inserting a nasogastric (NG) tube into the patient, what findings should the nurse anticipate?

A nurse is caring for a client who has just been admitted to the medical-surgical unit from the emergency department.The nurse is reviewing the client’s medical records.Which of the following conditions is the client most likely experiencing, based on the client’s notes and actions to be taken?

A nurse is educating a group of pregnant women about neural tube defects.Which of the following conditions should the nurse mention as an example of a neural tube defect?

A nurse is caring for a client diagnosed with gastrointestinal bleeding.Which of the following actions should the nurse take first?

A pregnant couple at 14 weeks gestation has just been told that they both are carriers of an autosomal-recessive disorder.The nurse who is providing genetic counseling should take which of the following actions?

A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition.Which of the following instructions should be included?

A nurse in the emergency department is implementing a plan of care for an older adult patient who is experiencing delirium tremens.What is the first action the nurse should take?

The nurse is educating a female client about the onset of menopause and the resulting atrophy of the vulvar organs.The nurse should recognize that the major cause for these symptoms is related to which of the following?

A nurse is administering Packed Red Blood Cells (PRBC) to a client who reports having lower back pain and feeling chilled and itchy.
Which of the following actions should the nurse take first?