A nurse is caring for a client who is experiencing chills and back pain during a blood transfusion. What should be the nurse’s priority action?

Assess the client’s skin for a rash.

Notify the provider.

Cover the client with a blanket.

Stop the transfusion.

Answer and Explanation

The Correct Answer is D

Choice A rationale
While assessing the client’s skin for a rash could be part of the overall assessment of the client’s condition, it is not the priority action when a client is experiencing chills and back pain during a blood transfusion.
Choice B rationale
Notifying the provider is an important step when a client is experiencing a reaction to a blood transfusion, but it is not the first action that should be taken.
Choice C rationale

Covering the client with a blanket may provide comfort to the client, but it does not address the underlying issue of a potential transfusion reaction.
Choice D rationale
The priority action when a client is experiencing chills and back pain during a blood transfusion is to stop the transfusion. This is because these symptoms could indicate a transfusion reaction, which can be serious.

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Correct Answer is D

Explanation

Choice A rationale
While nutrition is important for recovery, consuming 35% of meals for 12 hours is not an immediate concern. The patient’s nutritional status can be addressed after more urgent issues are resolved.

Choice B rationale
Bedrest for 3 days post-surgery is not uncommon. While prolonged bedrest can lead to complications such as deep vein thrombosis, it is not the most immediate concern in this scenario.
Choice C rationale
A last bowel movement 2 days ago is not necessarily a concern unless the patient is experiencing discomfort or other symptoms of constipation. This can be addressed after more urgent issues are resolved.
Choice D rationale
This is the correct answer. Pain in the lower extremities following surgery could indicate a serious condition such as a blood clot. It is important to address this first to rule out any serious complications.

A. This is likely related to new-onset dementia. B. This is likely related to new-onset schizophrenia. C. This is likely related to new-onset hepatic encephalopathy. D. This is likely related to a new-onset UTI.

Correct Answer is C

Explanation

Choice C rationale
Hepatic encephalopathy is a condition that can cause confusion or delirium in patients with end-stage liver disease and increasing ascites. It occurs when the liver is unable to remove toxins from the blood, such as ammonia, which can then accumulate in the brain and affect mental function. This condition is common in patients with cirrhosis or end-stage liver disease, and can manifest as confusion, changes in sleep patterns, mood alterations, and, in severe cases, coma.
Choice A rationale
While dementia can cause confusion and changes in mental status, it is typically a progressive condition that develops over time. In the context of a patient with end-stage liver failure and

increasing ascites who is usually lucid, a sudden onset of confusion or delirium is more likely to be due to a condition related to their liver disease, such as hepatic encephalopathy.
Choice B rationale
Schizophrenia is a chronic mental disorder characterized by distortions in thinking, perception, emotions, language, sense of self, and behavior. It is not typically associated with end-stage liver disease or ascites. In the context of a patient with end-stage liver failure and increasing ascites who is usually lucid, a sudden onset of confusion or delirium is more likely to be due to a condition related to their liver disease, such as hepatic encephalopathy.
Choice D rationale
While a urinary tract infection (UTI) can cause confusion, especially in older adults, it would not typically be the primary suspect in a patient with end-stage liver failure and increasing ascites. In such a patient, hepatic encephalopathy is a more likely cause of confusion or delirium.

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A nurse is caring for a client who is experiencing chills and back pain during a blood transfusion. What should be the nurse’s priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who reports pain in their lower extremities following surgery. Which of the following should the nurse address first?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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