A nurse is assisting with the care of a client who is receiving packed red blood cells. During the infusion, the client states, 'My heart is racing. The nurse notes that the client's face has become flushed. Which of the following actions should the nurse take first?

Obtain the client's vital signs.

Notify the charge nurse.

Stop the transfusion.

Administer prescribed diphenhydramine.

Answer and Explanation

The Correct Answer is C

A.   Obtain the client's vital signs: Although vital signs are essential, stopping the transfusion is the first priority to prevent further reaction.
B.   Notify the charge nurse: Communication is important but not the immediate action.
C.   Stop the transfusion: The first action is to stop the infusion to halt exposure to the potential allergen.
D.   Administer prescribed diphenhydramine: Medication administration is secondary to stopping the transfusion.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "Minimize exposure to the sun and artificial ultraviolet light": UV light can trigger lupus flares, so sun protection is crucial.
B. "Avoid using moisturizing lotions on your skin.": Moisturizing lotions help prevent skin dryness, which is common in lupus patients.
C. "Use a sun-blocking agent with a sun protection factor of 10.": An SPF of 10 is too low for effective protection. A minimum of SPF 30 is recommended.
D. "Apply powder liberally to sensitive areas of skin.": Powders can irritate the skin and cause dryness, exacerbating skin issues in lupus.

A. Hypotension B. Bradycardia C. Hypertension D. Tachycardia E. Wheezing

Correct Answer is ["A","D","E"]

Explanation

A. Hypotension: A rapid drop in blood pressure is a hallmark symptom of anaphylaxis.
B. Bradycardia: Bradycardia is not a common finding in anaphylaxis. Tachycardia (rapid heart rate) is more typical due to compensatory mechanisms.
C. Hypertension: Anaphylaxis usually causes hypotension due to vascular leakage and vasodilation.
D. Tachycardia: Tachycardia is commonly seen in anaphylaxis as the heart attempts to compensate for the drop in blood pressure.
E. Wheezing: Wheezing is a sign of bronchospasm and respiratory distress, which is a common feature of anaphylaxis.

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A nurse is assisting with the care of a client who is receiving packed red blood cells. During the infusion, the client states, 'My heart is racing. The nurse notes that the client's face has become flushed. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

. A nurse is reinforcing discharge teaching with a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

The nurse knows the following are symptoms of anaphylaxis and they need to intervene quickly. (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

Which of the following is a common nursing diagnosis that the nurse will include in the plan of care for a patient with systemic lupus erythematosus (SLE)?

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The nurse is monitoring a patient who is receiving a blood transfusion. The nurse knows that which of the following symptoms may be caused by a transfusion reaction?

A nurse is reinforcing teaching with a client who has a new diagnosis of systemic lupus erythematosus (SLE). Which of the following information should the nurse include in the teaching?