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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hypokalemia can be caused by excessive loss of potassium from the gastrointestinal tract, such as from vomiting, diarrhea, or gastric suction.
B. Drinking a large amount of water is more likely to dilute sodium levels rather than potassium.
C. Alcohol abuse disorder is not a direct cause of low potassium levels.
D. Spironolactone is a potassium-sparing diuretic, and its use can lead to hyperkalemia, not hypokalemia.
Correct Answer is A
Explanation
A. Metabolic acidosis is characterized by a low pH, indicating an excess of acid in the body.
B. HCO3 above 26 mEq/L is more indicative of metabolic alkalosis.
C. PaCO2 above 45 mm Hg is indicative of respiratory acidosis.
D. PaO2 below 70 mm Hg is more related to oxygenation status and is not a direct indicator of metabolic acidosis.
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