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 ["B","D","E"]
Explanation
A. Case manager may be involved in coordinating overall care, but based on the current assessment findings, there is a more immediate need for rehabilitation services.
B. A respiratory therapist can help manage the client's oxygen therapy and monitor their lung function.
C. Diabetes nurse educator is not directly relevant to the client's current condition as described.
D. The client's flaccid right upper and lower extremities with decreased muscle tone and strength indicate a need for rehabilitation and physical therapy.
E. The client's difficulty feeding themselves suggests a need for occupational therapy to address activities of daily living (ADLs) and improve independence.
F. Enterostomal therapy nurse is not indicated based on the information provided. The client's issues are primarily related to mobility and activities of daily living.
Correct Answer is D
Explanation
A: End-stage renal failure is associated with fluid retention, making this client less likely to be at risk for fluid volume deficit.
B: Left-sided heart failure with an elevated BNP level suggests fluid overload, not deficit.
C: The client who has been NPO since midnight for endoscopy is not at risk for fluid volume deficit because the duration of fasting is not long enough to cause significant dehydration.
D: The client who has gastroenteritis and is febrile is at risk for fluid volume deficit because of the loss of fluids and electrolytes from vomiting and diarrhea, as well as the increased insensible water loss from fever.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.