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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale
An increase in intraocular pressure is not a cause of diabetic retinopathy. Diabetic retinopathy is caused by damage to the blood vessels in the retina due to high blood sugar levels.
Choice B rationale
While regular eye exams are important for patients with diabetes mellitus, having an eye exam every 2 years may not be sufficient for detecting and managing diabetic retinopathy. More frequent eye exams may be recommended depending on the patient’s condition.
Choice C rationale
Clouding of the lens is not a manifestation of diabetic retinopathy. This is a symptom of cataracts, not diabetic retinopathy. Diabetic retinopathy affects the blood vessels in the retina, not the lens of the eye.
Choice D rationale
Seeing spots, also known as floaters, is a common symptom of diabetic retinopathy. This occurs when blood and other fluids leak into the vitreous, the clear, jelly-like substance that fills the inside of the eye.

A. Decreased serum lipase. B. Increased serum calcium. C. Increased serum amylase. D. Decreased WBC.

Correct Answer is C

Explanation

Choice C rationale
In the context of suspected acute pancreatitis, an increase in serum amylase is one of the key laboratory findings. Pancreatitis is associated with inflammation of the pancreas, which can result in the release of digestive enzymes such as amylase and lipase into the bloodstream.
Therefore, elevated levels of these enzymes are often used as markers for acute pancreatitis.
Choice A rationale
Decreased serum lipase is not typically associated with acute pancreatitis. In fact, an increase in serum lipase is more commonly seen in acute pancreatitis. Lipase is a digestive enzyme produced by the pancreas, and its levels in the blood can rise when the pancreas is inflamed.
Choice B rationale
Increased serum calcium is not typically associated with acute pancreatitis. While hypercalcemia, or high calcium levels, can be a cause of pancreatitis, it is not a typical finding in the blood tests of patients with acute pancreatitis.
Choice D rationale
Decreased white blood cell (WBC) count is not typically associated with acute pancreatitis. In fact, an increase in WBC count can sometimes be seen in acute pancreatitis due to the body’s inflammatory response to the condition. Hypothyroidism Explore

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 educating a patient with diabetes mellitus about diabetic retinopathy. Which of the following statements should the nurse make to the patient?

Correct Answer is D

Explanation

A nurse admits a patient to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

Correct Answer is C

Explanation

A nurse is setting health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should be included in the plan?

A nurse is providing discharge instructions to a client who has hypertension, which has resulted in a transient ischemic attack (TIA). What information regarding blood pressure (BP) management should the nurse discuss with the client?

A nurse is attending to a client who has just been admitted due to an acute exacerbation of ulcerative colitis. What should be the nurse’s initial course of action?

A nurse is educating a parent of a child diagnosed with celiac disease. Which of the following food choices should the nurse include in the teaching?

A nurse is caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss. The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse’s first action?

A nurse is educating a patient about the risk factors for GERD (gastroesophageal reflux disease). Which of the following statements should the nurse include?

A nurse is providing care for a patient who had a stroke and is experiencing difficulty swallowing. Which of the following complications should the nurse monitor for in this patient?

A nurse is educating a client who has recently been diagnosed with gastroesophageal reflux disease (GERD). The client inquires about foods to avoid. Which food should the nurse advise the client to avoid?