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 ["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
Correct Answer is B
Explanation
A. Peripheral edema is more associated with hypervolemia, not hypovolemia.
B. Oliguria (decreased urine output) is a common finding in hypovolemia due to decreased blood volume and reduced renal perfusion.
C. Hypertension is not typically associated with hypovolemia; hypotension is more common.
D. Bradycardia is not a typical finding in hypovolemia; tachycardia is more likely as a compensatory response to maintain cardiac output.
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