The client admitted with sickle cell anemia crisis is being treated with a transfusion of 2 units of packed red blood cells (PRBC's) for a low hemoglobin. The cent demonstrating a new onset of chest pain. low back pain, tachycardia and anxiety. The nurse's immediate intervention is
Stop transfusion, run normal saline.
Administer morphine IV.
Administer epinephrine IM
Continue to monitor the infusion.
The Correct Answer is A
A. Stop transfusion, run normal saline is correct because the client is likely experiencing an acute hemolytic transfusion reaction (AHTR), which is life-threatening. The priority is to stop the transfusion immediately and maintain IV access with normal saline to prevent further hemolysis.
B. Administer morphine IV is incorrect because pain management is important, but stopping the transfusion is the immediate priority.
C. Administer epinephrine IM is incorrect because epinephrine is used for anaphylaxis, not hemolytic reactions.
D. Continue to monitor the infusion is incorrect because the transfusion must be stopped immediately to prevent worsening hemolysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Mini mental status exam at admission and discharge
Useful for cognitive function but not for acute changes.
B. Performing serial Glasgow Coma Scale exams
The GCS is the best tool for tracking changes in neurologic status over time.
C. Assessing pupils for reactivity, equality, symmetry, and accommodation
Important but not comprehensive.
D. Obtaining vital signs every four hours
Useful but does not specifically assess neurologic function.
Correct Answer is C
Explanation
A. Follows an object with eyes without nystagmus or strabismus
Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) control eye movement. CN XI does not control eye movement.
B. Moves the tongue out midline without tremors or deviation
Cranial nerve XII (hypoglossal nerve) controls tongue movement.
C. Moves the head and shoulders against resistance with equal strength
Cranial nerve XI (spinal accessory nerve) controls the sternocleidomastoid and trapezius muscles. If intact, the client can shrug shoulders and turn the head against resistance with equal strength.
D. Demonstrates full range of the neck
Full range of motion in the neck involves multiple muscles, not just those innervated by CN XI.
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