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 C

Explanation

A. "These organs assist with vitamin absorption."These organs are not involved in nutrient absorption.
B. "These organs are used in digestion." The thymus, spleen, and lymph nodes are not part of the digestive system.
C. "These organs are for immunity." These organs play essential roles in the immune system, including lymphocyte production, pathogen filtration, and immune response regulation.
D. "These organs regulate electrolyte balance." Electrolyte regulation is managed by the kidneys and endocrine system.

A. Liver Failure B. Thyroid Disorder C. Infection D. Cancer

Correct Answer is C

Explanation

A. Liver Failure: Lymph node enlargement is not a typical finding in liver failure. Common signs of liver failure include jaundice and ascites.
B. Thyroid Disorder: Thyroid disorders typically present with changes in metabolism, thyroid enlargement (goiter), or thyroid hormone imbalances rather than lymphadenopathy.
C. Infection: Painful, movable lymph nodes are commonly associated with bacterial or viral infections.
D. Cancer: Cancer-related lymphadenopathy is typically painless and associated with firm, fixed lymph nodes.

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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

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Correct Answer is C

Explanation

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