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

Answer and Explanation

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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Correct Answer is B

Explanation

A. This is not typical for Raynaud's phenomenon. Instead, Raynaud's is characterized by episodes of reduced blood flow to the extremities, often triggered by cold or stress, leading to sensations of coldness or numbness rather than warmth.
B. This finding aligns with Raynaud's phenomenon. During an episode, the blood vessels constrict in response to cold or stress, leading to pallor (whiteness) in the affected areas, such as the toes and fingers. This is a classic symptom of the condition.
C. While feet can become reddened due to increased blood flow after rewarming or after exposure to warmth, this is not a characteristic feature of Raynaud's phenomenon. In Raynaud's, the affected areas typically exhibit color changes from white (pallor) to blue (cyanosis) and then red (hyperemia) as blood flow returns, but redness upon ambulation is not specifically indicative of the phenomenon.
D. Swelling of the joints can occur in SLE due to arthritis or inflammation but is not a direct symptom of Raynaud's phenomenon. Raynaud's primarily affects blood flow and does not inherently cause joint swelling; however, a client with SLE may experience joint symptoms due to other underlying inflammatory processes.

A. High serum Iron and Low MCV B. High serum Iron and Mean Corpuscular Volume (MCV) C. High Total Iron Binding Capacity: Low serum Iron and MCV D. None of the above

Correct Answer is C

Explanation

A. In iron deficiency anemia, serum iron levels are typically low due to a deficiency in iron. Additionally, the Mean Corpuscular Volume (MCV) is often low because the red blood cells produced are smaller than normal (microcytic).
B. Similar to option A, serum iron levels in iron deficiency anemia would be low, not high. The MCV may be low or normal, but it would not be high due to the production of microcytic red blood cells.
C. In iron deficiency anemia, TIBC is usually high because the body is trying to maximize iron transport in response to low iron levels. Serum iron is low, and the MCV is low due to the production of smaller red blood cells.
D. This option is incorrect because option C accurately describes the expected lab results in iron deficiency anemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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