A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?

Stop the transfusion.

Administer diphenhydramine.

Obtain vital signs.

Notify the registered nurse.

Answer and Explanation

The Correct Answer is A

A. Stop the transfusion: Stopping the transfusion is the priority action to prevent further exposure to the antigen causing the reaction.

B. Administer diphenhydramine: Administering diphenhydramine is an appropriate intervention for allergic reactions, but stopping the transfusion should be done first to halt the reaction source.

C. Obtain vital signs. Obtaining vital signs is important but should follow stopping the transfusion to address the immediate risk of reaction.

D. Notify the registered nurse: Notifying the registered nurse is necessary but comes after stopping the transfusion to immediately mitigate the reaction.

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Correct Answer is B

Explanation

A. Thyroid disease: While some thyroid diseases may indirectly contribute to anemia, thyroid disease itself does not directly cause low hemoglobin and hematocrit.

B. Anemia: Low hemoglobin and hematocrit levels indicate anemia, which can be caused by various factors, including blood loss, iron deficiency, or chronic disease.

C. Acute bronchitis: Acute bronchitis typically affects respiratory function and does not directly cause a decrease in hemoglobin or hematocrit.

D. Hemochromatosis: Hemochromatosis is characterized by excess iron in the body, often resulting in elevated rather than decreased hemoglobin and hematocrit.

A. Blood pressure B. Skin assessment C. Breath sounds D. Oxygen saturation E. WBC count F. Retractions G. Respiratory rate H. Hemoglobin

Correct Answer is ["B","C","D","F","G"]

Explanation

A. Blood pressure: The blood pressure is within normal limits and does not indicate an acute issue in this context.

B. Skin assessment: The presence of pallor and bruising indicates potential anemia and thrombocytopenia, common in leukemia patients but concerning signs that need to be monitored.

C. Breath sounds: Rhonchi in the upper lobes suggest respiratory congestion or infection, which is dangerous in an immunocompromised child.

D. Oxygen saturation: A drop in oxygen saturation to 90% indicates impaired oxygenation, which could signify respiratory distress or worsening infection.

E. WBC count: Although WBC count is within the low-normal range, it does not independently indicate an immediate change in the child’s condition.

F. Retractions: Subcostal retractions indicate respiratory distress, which is critical to report as it could escalate quickly in a child.

G. Respiratory rate: The increased respiratory rate (from 22 to 30/min) reflects respiratory distress and may worsen if the infection progresses.

H. Hemoglobin: While low, the hemoglobin is not acutely life-threatening in this case and would not necessarily prompt urgent intervention without other symptoms.

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A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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