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 C
Explanation
Choice A rationale
While heart failure can lead to fluid volume imbalances, a BNP level of 600 pg/mL alone does not indicate a risk for fluid volume deficit.
Choice B rationale
Being NPO since midnight for an endoscopy could potentially lead to fluid volume deficit, but it’s not the most likely choice. Typically, patients are adequately hydrated before and after the procedure.
Choice C rationale
A patient with gastroenteritis and a fever is at high risk for fluid volume deficit. Gastroenteritis can cause significant fluid loss through vomiting and diarrhea, and fever increases insensible water loss.
Choice D rationale
While patients with end-stage renal failure can have fluid volume imbalances, they are more likely to experience fluid volume excess, especially if they are due for dialysis.
Correct Answer is C
Explanation
Choice A rationale
Hyperthermia and severe tachycardia are not typical symptoms of damage to the parathyroid glands.
Choice B rationale
Hypercalcemia and shortness of breath are not typical symptoms of damage to the parathyroid glands.
Choice C rationale
Laryngospasms and tingling in the hands and feet can be symptoms of hypoparathyroidism, a condition that can occur if the parathyroid glands are damaged. Hypoparathyroidism can lead to low levels of calcium in the blood, which can cause these symptoms.
Choice D rationale
Hypophosphatemia, hypertension, vomiting, and chest pain are not typical symptoms of damage to the parathyroid glands.
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