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.

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

Explanation

Choice A reason: Kussmaul breathing is a deep, labored breathing pattern that is a compensatory mechanism for metabolic acidosis, commonly seen in diabetic ketoacidosis.

Choice B reason: Abdominal pain is a common symptom in diabetic ketoacidosis due to the metabolic disturbances and dehydration.

Choice C reason: A positive Trousseau sign is associated with hypocalcemia and is not a common manifestation of diabetic ketoacidosis.

Choice D reason: Decreased heart rate is not typical in diabetic ketoacidosis. In fact, patients might present with an increased heart rate due to dehydration and acidosis.

Choice E reason: Confusion is a symptom of diabetic ketoacidosis due to the effects of severe hyperglycemia and metabolic acidosis on the brain.

A. Start with a rapid infusion rate to meet the patient's nutritional needs as quickly as possible. B. Initiate the infusion slowly and monitor the patient's fluid and glucose tolerance. C. Change the rate of administration every 4 hours based on serum electrolyte values. D. Increase the rate of infusion at mealtimes to mimic the circadian rhythm of the body.

Correct Answer is B

Explanation

Choice A reason: Starting with a rapid infusion rate to meet the patient's nutritional needs as quickly as possible is not recommended. Rapid infusion can cause complications such as fluid overload, hyperglycemia, and electrolyte imbalances. It is important to start TPN at a slow rate and gradually increase it as tolerated.

Choice B reason: Initiating the infusion slowly and monitoring the patient's fluid and glucose tolerance is the appropriate action. This allows the nurse to assess the patient's response to TPN, prevent complications, and make necessary adjustments to the infusion rate.

Choice C reason: Changing the rate of administration every 4 hours based on serum electrolyte values is not a standard practice. The rate should be adjusted based on the patient's overall tolerance and clinical condition, rather than frequent changes.

Choice D reason: Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body is not appropriate for TPN. TPN is typically administered continuously over 24 hours to provide steady nutrition and prevent complications.

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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

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Explanation

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