A nurse is caring for a client who is receiving a transfusion of packed red blood cells and develops itching and hives. What should be the nurse’s first response?
Obtain vital signs.
Notify the registered nurse.
Administer diphenhydramine.
Stop the transfusion.
The Correct Answer is D
Rationale for Choice A: Obtain vital signs
While obtaining vital signs is important in assessing a patient's overall condition, it is not the first priority in a suspected transfusion reaction.
Vital signs can provide valuable information about the severity of the reaction, but they should not delay the immediate action of stopping the transfusion.
Delaying the cessation of the transfusion could allow for further infusion of incompatible blood or allergens, potentially worsening the reaction and leading to more serious complications.
Rationale for Choice B: Notify the registered nurse
Involving other healthcare professionals is crucial in managing transfusion reactions, but it should not precede stopping the transfusion.
The nurse should prioritize stopping the transfusion to prevent further exposure to potential triggers and then promptly notify the registered nurse for further assessment and interventions.
Timely communication with the registered nurse is essential for coordinating care and ensuring appropriate treatment measures are implemented.
Rationale for Choice C: Administer diphenhydramine
Diphenhydramine, an antihistamine, can be used to treat allergic reactions, but it should not be administered as the first response in this scenario.
The priority is to halt the infusion of the blood product that is potentially causing the reaction.
Administering diphenhydramine before stopping the transfusion could mask the symptoms of the reaction, making it more difficult to assess its severity and progression.
Rationale for Choice D: Stop the transfusion
This is the correct and most immediate action to take when a patient develops itching and hives during a blood transfusion.
These symptoms are indicative of a possible allergic or transfusion reaction, and stopping the transfusion is essential to prevent further complications.
It's critical to act quickly to minimize the amount of incompatible blood or allergens that enter the patient's circulation.
By stopping the transfusion, the nurse can potentially prevent the reaction from worsening and safeguard the patient's well- being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["50"]
Explanation
Here are the steps to calculate the gtt/min for the manual IV infusion:
Step 1: Convert the infusion time from hours to minutes. 8 hours x 60 minutes/hour = 480 minutes
Step 2: Divide the total volume of fluid (in mL) by the infusion time in minutes to get the mL/min rate. 400 mL ÷ 480 minutes = 0.8333 mL/min
Step 3: Multiply the mL/min rate by the drop factor (gtt/mL) to get the gtt/min rate. 0.8333 mL/min x 60 gtt/mL = 50 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
Correct Answer is B
Explanation
Choice B rationale:
Stridor is a high-pitched, wheezing sound that is heard during inspiration. It is caused by a narrowing or obstruction of the upper airway. This can be a serious complication after extubation, as it can indicate that the patient is not able to breathe adequately. Stridor can be caused by a number of factors, including:
Laryngeal edema: This is swelling of the larynx, which can be caused by irritation from the endotracheal tube.
Laryngospasm: This is a sudden constriction of the muscles of the larynx, which can be caused by irritation or by a foreign body in the airway.
Vocal cord paralysis: This is a loss of movement of the vocal cords, which can be caused by damage to the nerves that control them.
Blood or secretions in the airway: These can obstruct the airway and cause stridor.
It is important for the nurse to report stridor to the provider immediately so that the cause can be identified and treated. Treatment may include:
Oxygen therapy: This can help to improve the patient's breathing.
Medications: These may be used to reduce inflammation or to relax the muscles of the airway. Reintubation: This may be necessary if the patient is not able to breathe adequately on their own.
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