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: 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.

A. Consume only vegetable proteins B. Limit his ﬂuid intake to 1500 mL or less per day C. Avoid taking drugs that may be nephrotoxic D. Self-catheterize for residual urine at least once a week

Correct Answer is C

Explanation

Choice A reason (acute renal failure): Patients recovering from acute renal failure are not typically restricted to only vegetable proteins. Protein needs can vary based on the individual's condition and treatment plan.

Choice B reason (acute renal failure): Fluid intake recommendations for patients recovering from acute renal failure depend on their current kidney function and ﬂuid balance status. A blanket restriction to 1500 mL or less per day may not be appropriate for all patients.

Choice C reason (acute renal failure): Avoiding nephrotoxic drugs is crucial for patients recovering from acute renal failure to prevent further kidney damage.

Choice D reason (acute renal failure): Self-catheterization for residual urine is not a standard recommendation for all patients recovering from acute renal failure. This would be specific to patients with urinary retention 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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