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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Hip arthroplasty, or hip replacement surgery, is a procedure that has been associated with a higher risk of deep vein thrombosis (DVT)8910. This is due to factors such as the length of the
procedure, the immobility of the patient during and after the procedure, and the location of the surgery in the lower extremities.
Choice B rationale
Cataract extraction is not typically associated with a high risk of DVT8910. This is a relatively quick and minimally invasive procedure, and it does not involve the lower extremities, which are the most common sites for DVT8910.
Choice C rationale
Myringotomy, a procedure to drain fluid from the middle ear, is not associated with a high risk of DVT8910. This is a quick and minimally invasive procedure, and it does not involve the lower extremities.
Choice D rationale
Laparoscopic appendectomy, while a surgical procedure, is not typically associated with a high risk of DVT8910. The risk of DVT is generally lower with laparoscopic procedures compared to open surgeries.
Correct Answer is B
Explanation
Choice A rationale
While dietary iron restrictions can contribute to iron-deficiency anemia, they are not typically a symptom of ulcerative colitis. Ulcerative colitis is an inflammatory bowel disease that primarily affects the colon and rectum, and its symptoms are generally related to inflammation and damage in these areas.
Choice B rationale
Chronic blood loss is a common symptom of ulcerative colitis and a major contributing factor to the development of anemia in these patients. This is because the inflammation and ulceration in the colon and rectum can lead to bleeding, which over time can result in a significant loss of red blood cells.
Choice C rationale
Frequent diarrhea is a common symptom of ulcerative colitis, but it does not directly contribute to the development of anemia. However, severe or prolonged diarrhea can lead to malnutrition and malabsorption of nutrients, including iron, which could indirectly contribute to anemia.
Choice D rationale
Abdominal pain is a common symptom of ulcerative colitis, but it does not directly contribute to the development of anemia. The pain is typically caused by inflammation and ulceration in the colon and rectum, not by a loss of red blood cells.
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