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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: An RBC count of 4,500,000/mL is within the normal range and would not typically cause symptoms of anemia.
Choice B reason: Normal RBC indices do not indicate anemia and would not explain the symptoms.
Choice C reason: A hemoglobin level of 8.2 g/dL is below the normal range and would be consistent with symptoms of anemia such as fatigue and palpitations.
Choice D reason: A hematocrit of 38% is within the normal range for adult males and would not typically be associated with anemia symptoms.
Correct Answer is A
Explanation
Choice A reason: Hypertension is a well-known modifiable risk factor for stroke. Controlling blood pressure can significantly reduce the risk of having a stroke.
Choice B reason: A history of sickle cell disease is a genetic condition and is not considered a modifiable risk factor.
Choice C reason: Having a parent with cardiovascular disease is a non-modifiable risk factor as it is related to genetics.
Choice D reason: Age is a non-modifiable risk factor for stroke. The risk of stroke increases with age.
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