Packed red blood cells have been prescribed for a female patient with anemia who has a hemoglobin of 6.7 g/dL and a hematocrit level of 30%. The nurse takes the patient’s temperature before hanging the blood transfusion and records 100.7 degrees Fahrenheit orally. Which action should the nurse take?
Delay hanging the blood and notify the primary health care provider
Administer an ordered antihistamine and begin the transfusion
Administer two tablets of acetaminophen and begin the transfusion
Begin the transfusion as prescribed
The Correct Answer is A
Choice A reason: Delaying the transfusion and notifying the provider is critical, as a fever of 100.7°F suggests possible infection or inflammation. Transfusing blood in a febrile patient risks exacerbating underlying infection or causing transfusion reactions. The provider must evaluate the fever’s cause to ensure safe administration and prevent complications like sepsis or hemolytic reactions.
Choice B reason: Administering an antihistamine and starting the transfusion is inappropriate, as antihistamines address allergic reactions, not fever. A temperature of 100.7°F indicates potential infection, requiring investigation before transfusion. Proceeding without addressing the fever risks worsening an underlying condition or causing transfusion-related complications, making this an unsafe action.
Choice C reason: Administering acetaminophen to reduce fever and starting the transfusion is incorrect, as it masks the fever without identifying its cause. A temperature of 100.7°F may indicate infection, which must be evaluated before transfusion to avoid complications like sepsis. Treating symptoms without investigation compromises patient safety in this scenario.
Choice D reason: Beginning the transfusion as prescribed is unsafe with a fever of 100.7°F, as it may indicate infection or inflammation. Transfusing without investigating the fever risks exacerbating underlying conditions or causing transfusion reactions. Delaying and notifying the provider ensures the cause is addressed, prioritizing patient safety and appropriate management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Heart failure is not directly caused by vasopressin in CAD patients. Vasopressin increases water reabsorption in the kidneys, potentially increasing blood volume, which could strain the heart in severe cases. However, its primary concern in CAD is vasoconstriction, not heart failure, as it does not directly impair cardiac contractility or cause decompensation.
Choice B reason: Thirst is a symptom of diabetes insipidus due to dehydration from excessive urine output, not a side effect of vasopressin. Vasopressin replaces ADH, reducing urine output and thirst. It does not induce thirst in CAD patients, making this choice irrelevant to the cardiovascular risks associated with vasopressin administration.
Choice C reason: Dysrhythmias are not a primary concern with vasopressin in CAD. Vasopressin causes vasoconstriction, increasing vascular resistance and myocardial oxygen demand, which can lead to ischemia in CAD patients. While ischemia may rarely trigger dysrhythmias, the direct effect of vasopressin is vasoconstriction, not arrhythmias, making this choice less accurate.
Choice D reason: Vasoconstriction is a significant risk of vasopressin in CAD patients. Vasopressin, an ADH analog, causes systemic vasoconstriction, increasing blood pressure and myocardial oxygen demand. In CAD, this can exacerbate ischemia by reducing coronary blood flow, potentially leading to angina or infarction, making caution necessary in these patients.
Correct Answer is D
Explanation
Choice A reason: A serum chloride level of 98 mEq/L is within the normal range (97–107 mEq/L). It does not indicate an immediate issue in a patient receiving IV insulin. Chloride levels may shift in DKA or other conditions, but this value is normal and does not require urgent intervention, as it poses no immediate risk to cardiac or metabolic function.
Choice B reason: A serum sodium level of 137 mEq/L is within the normal range (135–145 mEq/L). Sodium levels may fluctuate in hyperglycemia due to osmotic shifts, but this value is stable. It does not warrant immediate intervention in a patient on IV insulin, as it does not indicate a critical imbalance affecting neurological or cardiovascular function.
Choice C reason: A serum calcium level of 8.8 mg/dL is within the normal range (8.5–10.2 mg/dL). Calcium levels are not directly affected by IV insulin therapy, and this value does not indicate a critical issue. No immediate intervention is needed, as it does not pose a risk to neuromuscular or cardiac function in this context.
Choice D reason: A serum potassium level of 2.5 mEq/L is critically low (normal: 3.5–5.0 mEq/L). IV insulin drives potassium into cells, worsening hypokalemia, which can cause life-threatening arrhythmias, muscle weakness, or respiratory failure. Immediate intervention, such as potassium supplementation, is required to prevent cardiac complications and ensure patient safety during insulin therapy.
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