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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Perform hand hygiene before and after care: Hand hygiene is the most effective way to prevent infection transmission.
B. Implement neutropenic precautions: This is important but comes after basic infection control measures.
C. Move the client to a positive-airflow room: Positive airflow rooms are used for highly immunocompromised clients but are not the first action.
D. Ensure all visitors wear masks: This is a precautionary measure but secondary to hand hygiene.
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