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 C

Explanation

A. This is incorrect because the time limit is shorter than 30 minutes.
B. This is also incorrect. You need to start the transfusion sooner than this timeframe.
C. You should start the transfusion within 15 minutes after the blood product is issued from the blood bank. This guideline is critical to minimize the risk of bacterial growth and ensure the safety of the transfusion.
D. The time limit is shorter than 60 minutes, emphasizing the urgency in starting the transfusion to maintain the integrity of the blood product.

A. Timolol eyedrops B. Acetaminophen C. Aspirin D. Banana bag

Correct Answer is D

Explanation

A. Timolol is a beta-blocker used primarily to treat glaucoma by reducing intraocular pressure. It would not address the issues presented by this patient, who is likely dealing with alcohol-related complications.
B. Acetaminophen is used to relieve pain and reduce fever. While the patient reports a severe headache, administering acetaminophen may not be advisable due to potential liver damage from alcohol use, especially if the patient has not eaten properly. Chronic alcohol use can also increase the risk of hepatotoxicity with acetaminophen.
C. Aspirin is another pain reliever that could potentially be used for headaches. However, like acetaminophen, it carries risks for patients with alcohol use, particularly gastrointestinal bleeding. Additionally, aspirin should be used cautiously in cases of possible liver impairment.
D. A "banana bag" is a term for an intravenous solution often used in patients with alcohol use disorder to provide hydration and essential vitamins, especially thiamine, which can prevent Wernicke's encephalopathy. It typically contains normal saline or dextrose, electrolytes, and vitamins (including B1, B6, and B12).

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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

You are planning to transfuse a unit of PRBC's to your patient. You know that when you arrive at the blood bank and they hand you the unit of blood, you have how long to start the transfusion from that time?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

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