A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?

Stop the transfusion immediately.

Inform the provider.

Call the lab and ask if this is really a transfusion reaction.

Obtain a urine specimen.

Answer and Explanation

The Correct Answer is A

Choice A reason: Stopping the transfusion immediately is the first and most critical action in response to signs of a possible transfusion reaction, which can be life-threatening.

Choice B reason: While informing the provider is a necessary step, it should come after stopping the transfusion to prevent further harm to the patient.

Choice C reason: Calling the lab is an appropriate action but not the first priority. The immediate concern is the patient's safety.

Choice D reason: Obtaining a urine specimen may be part of the diagnostic process for a transfusion reaction, but it is not the first action to take.

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Correct Answer is D

Explanation

Choice A reason: Urine output is important but not the priority after administration of fibrinolytic medication.

Choice B reason: Vital signs are routinely monitored but the priority is assessing for any signs of complications from the medication, such as bleeding or stroke.

Choice C reason: The name of the patient's dog is irrelevant to the patient's medical care and assessment.

Choice D reason: Neurological status is the priority to monitor for signs of intracranial hemorrhage, a potential complication of fibrinolytic therapy.

A. A client who told an assistive personnel he is short of breath B. A client who has a prescription for discharge C. A client who received oral pain medication 30 minutes ago D. A client who is scheduled for an abdominal x-ray and is awaiting transport

Correct Answer is A

Explanation

Choice A reason (client care): A client reporting shortness of breath may be experiencing a life-threatening situation that aligns with the ABCs (Airway, Breathing, Circulation) of patient prioritization. This client requires immediate assessment and intervention.

Choice B reason (client care): While discharge is important, it does not take precedence over a client with potential respiratory distress.

Choice C reason (client care): A client who received pain medication 30 minutes ago is likely stable and can be seen after more urgent cases are addressed.

Choice D reason (client care): A client waiting for an abdominal x-ray is not a priority over a client with respiratory issues.

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A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?

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