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
Hepatitis A is primarily transmitted through fecal contamination of food or water. This can occur when an infected person does not wash their hands properly after going to the bathroom and then touches food or other objects that others then put in their mouths.
Choice B rationale
While sexual intercourse can potentially transmit Hepatitis A, it is not the primary mode of transmission. The risk is higher if the sexual activity involves oral-anal contact.
Choice C rationale
Kissing mouth-to-mouth is not typically a primary mode of Hepatitis A transmission unless fecal particles are somehow involved.
Choice D rationale
Contact with infected blood is not the primary mode of Hepatitis A transmission. Hepatitis A is primarily spread through the fecal-oral route, not through blood.
Correct Answer is D
Explanation
Choice A rationale
An erythrocyte sedimentation rate (ESR) is a blood test that can detect and monitor inflammation in the body. It measures the rate at which red blood cells (erythrocytes) in a test tube separate from blood serum over time, with the rate being faster in people with inflammatory diseases. While it can be elevated in many conditions, including liver disease, it is not specific to liver disease and therefore would not typically be used to confirm a diagnosis of liver disease.
Choice B rationale
D-dimer is a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis. It is typically used to rule out thrombosis (blood clots), not to diagnose liver disease.
Choice C rationale
C-reactive protein (CRP) is a protein made by the liver and sent into the bloodstream in response to inflammation. While it can be elevated in many conditions, including liver disease, it is not specific to liver disease and therefore would not typically be used to confirm a diagnosis of liver disease.
Choice D rationale
Albumin is a protein made by the liver, and measuring its levels can help diagnose liver disease. When the liver is damaged, it can’t make enough albumin, so the level of albumin in the blood gets lower. This is why albumin is often used as a marker of liver function, and why it would be anticipated in the laboratory values ordered to confirm a diagnosis of liver disease.
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