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?
Stop the infusion of blood.
Notify the laboratory.
Obtain a urine specimen.
Inform the provider.
The Correct Answer is A
Choice A rationale
If a client reports chills and back pain during a blood transfusion, and their blood pressure is 80/64 mm Hg, the nurse’s first action should be to stop the infusion of blood. These symptoms could indicate an acute intravascular hemolytic transfusion reaction, and the greatest risk to the client is injury from receiving additional blood.
Choice B rationale
Notifying the laboratory is an important step in managing a transfusion reaction, but it is not the first action that should be taken.
Choice C rationale
Obtaining a urine specimen could be part of the overall assessment of the client’s condition, but it is not the first action that should be taken when a client is experiencing a potential transfusion reaction.
Choice D rationale
Informing 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While Vitamin B is important for overall health, it is not specifically known to promote wound healing.
Choice B rationale
Protein is essential for wound healing. It helps to repair body tissues and is vital for skin repair and immunity. Inadequate protein intake can impair collagen formation and slow down the wound healing process.
Choice C rationale
While calcium is important for bone health, it is not specifically known to promote wound healing.
Choice D rationale
Vitamin D helps the body absorb calcium, but it is not specifically known to promote wound healing.
Correct Answer is D
Explanation
Choice A rationale
Avoiding the use of tanning booths is an effective measure to prevent skin cancer as tanning booths emit harmful ultraviolet (UV) rays that can damage the skin and increase the risk of skin cancer.
Choice B rationale
Using sunscreen even on cloudy days is recommended as UV rays can penetrate through clouds and harm the skin.
Choice C rationale
Checking the skin monthly for any changes is a good practice as early detection of skin changes can lead to early diagnosis and treatment of skin cancer.
Choice D rationale
Eating a high fiber diet does not reduce the risk for developing skin cancer. While a healthy diet is important for overall health, it does not directly prevent skin cancer. Hypokalemia Explore
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