A nurse is caring for a client who is receiving a blood transfusion. The client reports itching and hives. Which of the following actions should the nurse take first?
Administer diphenhydramine
Stop the transfusion
Notify the provider
Obtain vital signs
The Correct Answer is B
Choice A reason: Administering diphenhydramine treats allergic symptoms but does not address the ongoing transfusion reaction. Stopping the transfusion prevents further allergen exposure, making this a secondary action.
Choice B reason: Stopping the transfusion is the first action, as itching and hives indicate an allergic reaction. Halting the infusion prevents worsening symptoms, like anaphylaxis, making this the priority intervention.
Choice C reason: Notifying the provider is necessary but follows stopping the transfusion. Ceasing the infusion immediately mitigates the reaction, ensuring patient safety, making notification a subsequent step.
Choice D reason: Obtaining vital signs provides data but delays addressing the reaction. Stopping the transfusion halts allergen administration, taking precedence over assessment, making this a secondary action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Potatoes do not contain substances that cause false-positive occult blood tests. They are low in heme and do not mimic blood in stool, making them safe to consume before testing.
Choice B reason: Red meat contains heme, which can cause false-positive results in occult blood tests by mimicking blood. Avoiding red meat for 48–72 hours ensures test accuracy, making this the correct choice.
Choice C reason: Yogurt lacks heme or oxidizing agents that interfere with occult blood tests. It is a safe food choice before testing, as it does not affect results, making this incorrect.
Choice D reason: Apples do not typically cause false positives, though some fruits with peroxidase (e.g., turnips) might. Apples are generally safe, making this less critical to avoid than red meat.
Correct Answer is D
Explanation
Choice A reason: Positioning on the right side is incorrect; the left side (Sim’s position) allows better solution flow into the colon. Right-side positioning hinders distribution, making this incorrect for enema administration.
Choice B reason: Cold tap water can cause cramping or shock. Warm water (105–110°F) ensures comfort and safety, making cold water incorrect for a cleansing enema solution.
Choice C reason: Inserting tubing 4 inches is excessive; 2–3 inches is sufficient for adults to reach the rectum safely. Deeper insertion risks injury, making this incorrect for proper technique.
Choice D reason: Holding the container 12 inches above the anus ensures safe, controlled flow, preventing pressure-related discomfort or injury. This standard height is correct for effective enema administration.
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