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 ["A","B","D","E"]

Explanation

A. Using a filtered IV line helps remove any particulate matter that could be present in the TPN solution, reducing the risk of complications such as phlebitis or embolism.
B. TPN should have its own dedicated line to prevent incompatibilities and ensure the TPN solution is delivered without interference. Infusing other medications through the same line can lead to complications and reduce the effectiveness of TPN.
C. If TPN gets stopped or runs out, a bag of 5% dextrose in water (D5W) should be hung to prevent hypoglycemia. D10% is too concentrated and can cause hyperglycemia.
D. To minimize the risk of infection and maintain sterility, TPN bags and tubing should be replaced every 24 hours. This helps prevent bacterial growth in the TPN solution.
E. TPN is typically administered through a central line because it allows for the infusion of hypertonic solutions that can irritate peripheral veins. Central lines provide better access to larger blood vessels, reducing the risk of complications.

A. Call the MD to report a potential Emergency B. Call the MD to request a X-ray of the shoulder C. Perform a head to toe assessment and then chart your findings D. Call the MD to request an increase to their opioid dosage

Correct Answer is A

Explanation

A. A sudden new pain in a patient with SCD can be a sign of a serious complication, such as acute chest syndrome or stroke. Prompt medical evaluation is crucial to identify and address any underlying complications.
B. While an X-ray may be helpful to rule out other causes of shoulder pain, it is not the most urgent priority in this case. The patient's sudden onset of pain could be a sign of a serious complication that requires immediate attention.
C. While a head-to-toe assessment is important for any patient, it is not the most urgent priority in this case. The patient's new pain could be a sign of a serious complication that requires immediate medical attention.
D. Increasing the opioid dosage may provide temporary relief from the pain, but it does not address the underlying cause of the new pain.

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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

Which of the following is are appropriate nursing interventions to ensure the safety of a patient who is receiving Total Parenteral Nutrition (TPN)? (Select all that apply)

Correct Answer is ["A","B","D","E"]

Explanation

You are caring for a patient who has Sickle Cell Disease (SCD) who is in the hospital for an acute worsening of their disease. Your patient is receiving ATC opioids for their severe pain, when they suddenly report a new sharp pain in their left shoulder. What is your BEST action?

Correct Answer is A

Explanation

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