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 C

Explanation

Choice A reason: While a stable ECG rhythm is important, it is not the immediate concern post-AMI.

Choice B reason: The ability to verbalize causes and eﬀects of CHD/CAD is an educational goal, not an immediate care priority.

Choice C reason: Adequate relief of pain is a priority to reduce stress on the heart and improve patient comfort.

Choice D reason: Compliance with prescribed bedrest is important but secondary to pain relief.

A. Movement of the trachea toward the unaﬀected side B. Crepitus in the area above and surrounding the insertion site C. Bubbling of the water in the water seal chamber with exhalation D. Eyelets are not visible

Correct Answer is A

Explanation

The correct answer is Choice A

Choice A rationale: Movement of the trachea toward the unaffected side indicates a possible tension pneumothorax, which is a life-threatening condition. This shift occurs due to the increased pressure on the affected side, pushing the trachea away. Immediate intervention is required.

Choice B rationale: Crepitus, or subcutaneous emphysema, can be a common finding around the chest tube insertion site. It indicates air leakage into the subcutaneous tissue but does not necessarily require immediate notification to the provider unless it is extensive or worsening.

Choice C rationale: Bubbling of the water in the water seal chamber with exhalation is expected and indicates that the chest tube is functioning properly by allowing air to escape from the pleural space. This is a normal finding in pneumothorax management.

Choice D rationale: The visibility of eyelets on the chest tube indicates that the tube is in the correct position within the pleural space. If the eyelets are not visible, it means the tube is not functioning correctly, but this is not as urgent as a tracheal shift.

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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?

Nursing Test Bank

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