The nurse assesses a patient 20 minutes after initiating a blood transfusion. The patient has itching and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What intervention will the nurse prioritize to implement first for this patient?

Notify the blood bank of the suspected transfusion reaction.

Maintain IV access with normal saline infusion.

Facilitate the transfer of the patient to the critical care unit.

Recheck identification labels and numbers.

Answer and Explanation

The Correct Answer is B

Choice A reason: Notifying the blood bank of the suspected transfusion reaction is important, but maintaining the IV access with normal saline infusion takes priority to ensure that the patient remains stable and to prevent any further complications.

Choice B reason: Maintaining IV access with normal saline infusion is the first priority. This action helps to keep the vein open, provide fluids, and flush out any remaining blood product from the IV line, reducing the risk of further reaction.

Choice C reason: Facilitating the transfer of the patient to the critical care unit may be necessary if the patient's condition worsens, but it is not the immediate first step.

Choice D reason: Rechecking identification labels and numbers is important to confirm the correct blood product was given, but it comes after ensuring the patient’s stability by maintaining IV access with saline.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Wheezing is a typical sound heard during bronchoconstriction, which occurs in conditions like asthma and COPD. It indicates that the airways are narrowed, causing the characteristic sound.

Choice B reason: Pulmonary edema typically presents with crackles or rales rather than wheezing. Wheezing would not be the primary indication of this condition.

Choice C reason: Hemoptysis refers to coughing up blood and does not typically present with wheezing. It might present with other sounds if there is an underlying lung issue, but wheezing is not specific to it.

Choice D reason: Pneumothorax generally presents with decreased or absent breath sounds on one side, not wheezing. It occurs when air enters the pleural space, causing lung collapse.

A. Kussmaul breathing B. Positive Chvostek sign C. Hematemesis D. Distended jugular vein

Correct Answer is B

Explanation

Choice A reason: Kussmaul breathing is a sign of metabolic acidosis, not metabolic alkalosis. It is characterized by deep, labored breathing as the body tries to expel excess carbon dioxide.

Choice B reason: Positive Chvostek sign is an indication of hypocalcemia, which can be associated with metabolic alkalosis. It is a facial muscle twitch that occurs when the facial nerve is tapped.

Choice C reason: Hematemesis, or vomiting blood, is not a clinical manifestation of metabolic alkalosis. It is more related to gastrointestinal bleeding.

Choice D reason: Distended jugular veins are more commonly associated with conditions such as heart failure and fluid overload, not specifically with metabolic alkalosis.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse assesses a patient 20 minutes after initiating a blood transfusion. The patient has itching and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What intervention will the nurse prioritize to implement first for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD) who is reporting dyspnea. The nurse auscultates the patient's chest and hears wheezing throughout the lung fields. What does this finding indicate to the nurse about this patient?

Correct Answer is A

Explanation

The nurse is caring for a patient who presents with metabolic alkalosis. Upon assessing the patient, which clinical manifestation will the nurse expect to find?

Correct Answer is B

Explanation

The nursing instructor is discussing heart failure during post-conference. Which statement by the student confirms their understanding of a contributing factor to a patient's increased risk for developing heart failure?

The nurse is caring for a patient with idiopathic thrombocytopenic purpura (ITP) whose platelet count is 10,000/mm³. What assessment finding will the nurse report to the provider immediately?

The nurse has just received a change of shift report on four patients. Which patient will the nurse assess first?

The nurse is teaching a patient who is scheduled for hemodialysis about the process and potential complications. Which of the following statements by the patient indicates to the nurse the need for further teaching? (Select All That Apply)

The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD) who is reporting dyspnea. The nurse auscultates the patient's chest and hears wheezing throughout the lung fields. What does this finding indicate to the nurse about this patient?

The nurse is caring for a patient after a barium enema. When assessing the patient's subsequent bowel patterns and stools, what finding will the nurse report to the health care provider?