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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Increasing the rate of maintenance IV infusion is not the first action the nurse should take when observing that the fetal heart rate begins to slow after the start of a contraction and the lowest rate occurs after the peak of the contraction. This pattern is known as late decelerations and is often associated with fetal hypoxemia due to insufficient placental perfusion.
Choice B rationale
The nurse should first place the client in the lateral position. This position can improve placental blood flow and may help to resolve the late decelerations.
Choice C rationale
Administering oxygen using a nasal cannula may be beneficial, but it is not the first action the nurse should take. The priority is to improve placental blood flow, which can be achieved by changing the client’s position.
Choice D rationale
Elevating the client’s legs is not the first action the nurse should take. This action would not directly address the issue of late decelerations.
Correct Answer is A
Explanation
Choice A rationale
Tremors are a common side effect of terbutaline. Terbutaline is a medication used to inhibit uterine contractions in preterm labor. It is a beta-adrenergic agonist, and stimulation of the beta-adrenergic receptors can lead to side effects such as tremors.
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