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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Correct Answer is B

Explanation

A. "You need to stay on antibiotics for the rest of your life."Lifelong antibiotic therapy is not standard post-transplant care, though immunosuppressants are required.
B. "You should avoid people that are sick to decrease the risk of you getting an infection." Immunosuppressive medications used post-transplant increase the risk of infections.
C. "You need to stay on antihistamines the rest of your life."Antihistamines are not a routine part of post-transplant care.
D. "You can drink as much alcohol as you want."Alcohol should be strictly avoided to protect the transplanted liver.

A. "Minimize exposure to the sun and artificial ultraviolet light" B. "Avoid using moisturizing lotions on your skin." C. "Use a sun-blocking agent with a sun protection factor of 10.1 D. "Apply powder liberally to sensitive areas of skin."

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.

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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?

Nursing Test Bank

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