A transfusion of packed red blood cells (PRBCs) has been infusing for 5 minutes when the patient becomes flushes and tachypneic and says, "I'm having chills. Please get me a blanket." Which action should the nurse take first?
Stop the transfusion
Administer oxygen
Obtain a blanket from the warmer
Check the patient's oral temperature
The Correct Answer is A
A. This is the first and most critical action to take. The patient's symptoms suggest a possible transfusion reaction, which can be life-threatening. Stopping the transfusion immediately prevents further exposure to potentially harmful blood components.
B. Administering oxygen may be necessary if the patient exhibits signs of respiratory distress or hypoxia. However, this action should come after ensuring that the transfusion is stopped and the patient is stabilized, as continuing the transfusion could exacerbate the reaction.
C. While providing warmth can help alleviate chills, it is not the priority action. The patient's safety is more important, and symptoms of a transfusion reaction must be addressed first.
D. Checking the temperature can provide useful information about the patient's condition, especially if a fever is present, but it is not an immediate priority. The focus should be on stopping the transfusion and managing the acute symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This statement is not typically related to rheumatoid arthritis. RA does not cause low blood sugar directly. While medications or other conditions might affect blood sugar levels, this is not a common symptom or concern specific to RA.
B. Morning stiffness is a hallmark symptom of rheumatoid arthritis. Patients often report increased stiffness and discomfort in their joints upon waking, which can improve with activity throughout the day.
C. While some individuals might gain weight due to reduced physical activity or medication side effects (like corticosteroids), weight loss is also common due to pain and decreased mobility. Thus, this statement is not universally applicable.
D. Abdominal pain is not a primary symptom of RA. However, certain medications used to treat RA, like nonsteroidal anti-inflammatory drugs (NSAIDs), can cause gastrointestinal discomfort, but this is not a direct result of the disease itself.
Correct Answer is A
Explanation
A. This statement indicates some understanding of self-care, as using gentle hair products can help minimize irritation. However, it's not specifically focused on the most critical aspects of SLE management related to skin care.
B. Clients with SLE should inspect their skin regularly, not just once a month, as they are at a higher risk for rashes and skin lesions. More frequent self-assessment can help catch any changes early.
C. Clients with SLE are generally advised to avoid tanning beds altogether, as ultraviolet (UV) exposure can exacerbate skin rashes and trigger flares of the disease. Limiting exposure to UV light is essential for managing lupus.
D. Applying powder to a rash may not be advisable, as it could irritate the skin further. Clients should be taught to keep the affected areas clean and follow their healthcare provider's recommendations for treating rashes.
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