A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?

Stopping the transfusion

Covering the client with a blanket

Assessing the client's skin for a rash

Notifying the provider

Answer and Explanation

The Correct Answer is A

A.   Stopping the transfusion is the priority action if the client is experiencing symptoms of a transfusion reaction.
B.   Covering the client with a blanket may address chills but does not address the potential serious nature of the reaction.
C.   Assessing the client's skin for a rash is important but should not delay the immediate action of stopping the transfusion.
D.   Notifying the provider is important, but stopping the transfusion and addressing the immediate needs of the client take precedence.

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Correct Answer is ["56"]

Explanation

To calculate the infusion rate for Ringer's lactate, we need to use the following formula: Infusion rate (gtt/min) = Volume (mL) x Drop factor (gtt/mL) / Time (min)

Plugging in the values from the question, we get:

Infusion rate (gtt/min) = 500 mL x 20 gtt/mL / 180 min Simplifying, we get:

Infusion rate (gtt/min) = 10000 gtt / 180 min Dividing, we get:

Infusion rate (gtt/min) = 55.56 gtt/min

Since we need to round the answer to the nearest whole number, the final answer is: Infusion rate (gtt/min) = 56 gtt/min

A. Bradycardia B. Peripheral edema C. Hypotension D. Oliguria

Correct Answer is B

Explanation

A: Hypervolemia is often associated with increased fluid volume, which typically results in an increased heart rate (tachycardia), not bradycardia.
B: Peripheral edema is a common manifestation of hypervolemia due to the excess fluid in the extracellular space.
C: Hypervolemia is more likely to cause increased blood pressure (hypertension), not hypotension.
D: Oliguria (decreased urine output) is associated with hypovolemia, not hypervolemia.

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A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["56"]

Explanation

A nurse is assessing a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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