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. "This medication will help my new kidney make adequate urine": Cyclosporine suppresses the immune system to prevent organ rejection but does not directly affect urine production.
B. "I will need to take this medication for the rest of my life": Lifelong immunosuppression is required to maintain the function of a transplanted organ.
C. "I will take this medication until my BUN returns to normal": The medication is necessary regardless of lab values to prevent rejection.
D. "This medication will boost my immune system": Cyclosporine suppresses, not boosts, the immune system.

A. Histamine release B. T-lymphocyte memory cells C. Immunosuppression D. Antigen/antibody interaction

Correct Answer is B

Explanation

Histamine release: Histamine release is characteristic of Type I hypersensitivity reactions (immediate hypersensitivity) rather than Type IV.

T-lymphocyte memory cells: Type IV hypersensitivity is a delayed response mediated by T-lymphocytes, not antibodies.

Immunosuppression: Immunosuppression is not directly related to hypersensitivity reactions.

Antigen/antibody interaction: This is characteristic of Types I, II, and III hypersensitivity reactions, not Type IV.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching about cyclosporine (an immunosuppression medication) for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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