A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five minutes after beginning the transfusion, the client becomes febrile with chills. After stopping the transfusion, which of the following actions should the nurse take?
Administer epinephrine subcutaneously.
Place the blood bag in a biohazard bag before discarding.
Document the reaction in the medical record.
Infuse 500 ml lactated Ringer's IV.
The Correct Answer is C
Choice A reason:
Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.
Choice B reason:
Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag.
Choice C reason:
Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.
Choice D reason
Infuse 500 ml lactated Ringer's IV.This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A is correct because aPTT (activated partial thromboplastin time) measures the effectiveness of heparin therapy and guides dosage adjustments.
B is incorrect because PT (prothrombin time) measures the effectiveness of warfarin therapy, not heparin.
C is incorrect because INR (international normalized ratio) is a standardized version of PT that also monitors warfarin therapy, not heparin.
D is incorrect because WBC count (white blood cell count) measures the body's immune response and has no relation to heparin therapy.
Correct Answer is C
Explanation
An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the
stool. It is usually oil-based and contains 90-120 ml of solution.
The temperature of the enema solution affects the effectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work.
The ideal temperature for an enema solution is close to the client's body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions .
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