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 B
Explanation
Choice A reason: Stroke Volume refers to the amount of blood pumped by the left ventricle of the heart in one contraction, not to the regulation of fluid volume and cardiac output.
Choice B reason: Renin-Angiotensin-Aldosterone-System (RAAS) is responsible for vasoconstriction, sodium retention, and water reabsorption, which helps to increase circulating fluid volume and cardiac output.
Choice C reason: Brain and Atrial natriuretic peptides (BNP & ANP) actually work to decrease blood volume and pressure, not increase them.
Choice D reason: Erythropoietin primarily stimulates red blood cell production and does not directly affect fluid volume or cardiac output.
Correct Answer is B
Explanation
Choice A reason: Dumping syndrome is not commonly associated with dysphagia post-stroke.
Choice B reason: Aspiration is a significant risk for patients with dysphagia following a stroke and should be closely monitored to prevent complications like aspiration pneumonia.
Choice C reason: Gastroesophageal reflux disease may occur but is not the most immediate concern for stroke patients with dysphagia.
Choice D reason: Peptic ulcer disease is not directly related to dysphagia and is less likely to be an immediate complication post-stroke.
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