A nurse is caring for a client who is receiving a blood transfusion and exhibits signs of a transfusion reaction. What is the priority intervention the nurse should take?
Administer 0.9% sodium chloride through the existing blood transfusion line.
Notify the provider and document the reaction before any other action.
Stop the transfusion and maintain IV access by infusing normal saline through new tubing.
Monitor vital signs every 30 minutes during the transfusion.
The Correct Answer is C
Rationale:
A. Using the same tubing may allow residual blood to continue entering the patient, which could worsen the reaction. Proper procedure requires new tubing to safely infuse saline.
B. Although notifying the provider and documenting are important, the priority is to stop the transfusion immediately to prevent further exposure and reduce risk of life-threatening complications.
C. Stopping the transfusion prevents further exposure to the incompatible blood product. Maintaining IV access with saline through new tubing allows for hydration, administration of emergency medications if needed, and collection of samples for evaluation, ensuring patient safety.
D. During a transfusion reaction, vital signs should be monitored continuously, not every 30 minutes, to promptly detect rapid changes such as hypotension, tachycardia, or respiratory distress. Continuous assessment is essential to intervene immediately if the patient’s condition deteriorates.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Clients with a history of substance use disorder are at risk for undertreatment of pain due to provider or nurse concerns about dependence. Pain management should be based on clinical assessment and patient-reported pain, using prescribed analgesics while closely monitoring for efficacy, side effects, and potential misuse. This approach ensures adequate pain relief without stigmatization or undertreatment.
B. Withholding pain medication based solely on a history of substance use is unethical and unsafe. It can lead to unnecessary suffering, withdrawal, or escalation of pain-related stress, and does not address the immediate need for pain relief. Psychiatric evaluation may be helpful for comorbid conditions, but it does not replace pain management.
C. This is unsafe because it discourages honest communication, may result in inadequate analgesia, and does not reduce risk of dependence in a controlled, clinically monitored setting. Pain should always be assessed and treated objectively.
D. Non-pharmacological strategies (e.g., heat, relaxation, physical therapy) can be adjuncts but are not sufficient for moderate to severe pain. Complete reliance on these methods may result in untreated pain and unnecessary suffering.
Correct Answer is A
Explanation
Rationale:
A. Hyperparathyroidism is characterized by overproduction of parathyroid hormone (PTH). PTH stimulates osteoclast activity, which breaks down bone tissue and releases calcium into the bloodstream, leading to hypercalcemia. Other effects of elevated PTH include increased renal calcium reabsorption and enhanced activation of vitamin D, which further increases intestinal calcium absorption.
B. In hyperparathyroidism, PTH promotes conversion of vitamin D to its active form (calcitriol), which enhances intestinal absorption of calcium rather than decreasing it. Low intestinal calcium absorption is more associated with vitamin D deficiency, not primary hyperparathyroidism.
C.PTH actually increases renal calcium reabsorption in the distal tubules. Decreased reabsorption would result in calcium loss and hypocalcemia, which is opposite of what occurs in hyperparathyroidism.
D. PTH is elevated in hyperparathyroidism, not low. Increased calcium excretion (hypercalciuria) can occur secondary to extremely high serum calcium levels, but it is not due to low PTH.
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