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 A
Explanation
Choice A reason: Packed RBCs should be transfused as soon as possible once the nurse has prepared everything necessary for the transfusion.
Choice B reason: Waiting 2 hours after obtaining the blood is not necessary and could delay needed treatment.
Choice C reason: The client's mealtime should not delay the transfusion of blood, which is a time-sensitive medical treatment.
Choice D reason: While the client's readiness is important, it should not unduly delay the transfusion if the client is medically stable and the transfusion is necessary.
Correct Answer is A
Explanation
Choice A reason: Hyperkalemia is a common electrolyte imbalance in prerenal AKI due to decreased kidney function and the inability to excrete potassium.
Choice B reason: Hypernatremia is not typically expected in prerenal AKI unless there is an associated condition causing increased sodium retention.
Choice C reason: Hypercalcemia is not commonly associated with prerenal AKI.
Choice D reason: Hypophosphatemia is less likely in prerenal AKI; hyperphosphatemia is more common due to decreased filtration of phosphate.
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