A nurse is assessing a client who is receiving a unit of packed RBCs. The client appears flushed and reports low-back pain. After stopping the transfusion, which intervention is important to complete FIRST?
Call the provider.
Notify the blood bank.
Collect a urine specimen.
Keep the line open with 0.9% NS through new tubing.
The Correct Answer is D
Choice A Reason:
“Call the provider” is important but not the first priority. The immediate concern is to maintain the client’s intravenous access to ensure they can receive any necessary medications or fluids promptly. Once the line is secured, the provider should be notified to receive further instructions and manage the client’s condition.
Choice B Reason:
“Notify the blood bank” is also crucial but comes after ensuring the client’s immediate safety. The blood bank needs to be informed to investigate the cause of the reaction and prevent further issues, but this step follows the initial emergency interventions.
Choice C Reason:
“Collect a urine specimen” is necessary to check for hemolysis, which can occur during a transfusion reaction. However, this is not the first step. The priority is to stabilize the client by maintaining IV access with normal saline.
Choice D Reason:
“Keep the line open with 0.9% NS through new tubing” is the correct first intervention. This action ensures that the client remains hydrated and that the IV line is available for any emergency medications or treatments. Using new tubing prevents any contamination from the transfusion set.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Ask close-ended questions is incorrect. Close-ended questions typically elicit short, specific responses such as “yes” or “no.” While they can be useful in certain situations, they do not provide enough information to thoroughly assess a client’s mental status. Open-ended questions allow the client to express themselves more fully, providing the nurse with better insight into their cognitive function.
Choice B Reason:
Ask open-ended questions is correct. Open-ended questions encourage the client to elaborate on their thoughts and feelings, which can reveal more about their mental status. This type of questioning helps the nurse assess the client’s orientation, memory, and thought processes more effectively.
Choice C Reason:
Use directive questions is incorrect. Directive questions are more structured and guide the client towards specific answers. While they can be useful for obtaining specific information, they do not allow for a comprehensive assessment of the client’s mental status.
Choice D Reason:
Use reflective questions is incorrect. Reflective questions are used to encourage the client to think more deeply about their responses and feelings. While they can be helpful in therapeutic settings, they are not the most effective for an initial assessment of mental status.
Correct Answer is A
Explanation
Choice A Reason:
When calculating the fluid balance for a client undergoing continuous bladder irrigation (CBI), the irrigation solution must be deducted from the total urine output. This is because the irrigation fluid is not part of the client’s actual urine production but is an additional fluid introduced into the bladder to prevent or remove blood clots and ensure catheter patency. By deducting the irrigation solution from the total urine output, the nurse can accurately determine the client’s true urine output and fluid balance.
Choice B Reason:
Subtracting the irrigation solution from the intravenous flow sheet as output is incorrect. The intravenous flow sheet is used to document fluids administered intravenously, not those introduced into the bladder. Therefore, this choice does not apply to the management of continuous bladder irrigation.
Choice C Reason:
Documenting the intake hourly in the urine output column is also incorrect. The urine output column should reflect the actual urine produced by the client, not the irrigation solution. Including the irrigation solution in this column would lead to an inaccurate representation of the client’s urine output and fluid balance.
Choice D Reason:
Adding the irrigation solution to the oral intake column is incorrect as well. The oral intake column is designated for fluids consumed orally by the client. The irrigation solution is introduced directly into the bladder and should not be recorded as oral intake.
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