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","C"]

Explanation

Choice A reason: A pH less than 7.35 indicates an acidic state, which is consistent with metabolic acidosis. The normal pH range is 7.35 to 7.45.

Choice B reason: HCO3 (bicarbonate) less than 22 mEq/L indicates a low level of bicarbonate, which is consistent with metabolic acidosis. Bicarbonate is a base, and lower levels indicate a loss of buffering capacity.

Choice C reason: PaCO2 greater than 45 mmHg is not a primary indicator of metabolic acidosis but can occur as a compensatory mechanism in response to respiratory acidosis. The primary indicators of metabolic acidosis are low pH and low bicarbonate.

Choice D reason: PaO2 less than 80 mmHg indicates hypoxemia but is not directly related to the diagnosis of metabolic acidosis. Hypoxemia can occur with various conditions, and while it may be present, it is not a defining characteristic of metabolic acidosis.

Choice E reason: SpO2 greater than 95% indicates normal oxygen saturation and is not relevant to the diagnosis of metabolic acidosis. Oxygen saturation primarily reflects respiratory function rather than acid-base balance.

A. "Young people do not have to worry about heart failure, just older people." B. "Progressive kidney failure contributes to the development and severity of heart failure." C. "The elderly patient used cocaine as a teenager and complains of occasional anxiety." D. "The patient takes 20mg of losartan every day and their potassium level is 3.8 mEq/L."

Correct Answer is B

Explanation

Choice A reason: The statement that young people do not have to worry about heart failure, just older people, is incorrect. While heart failure is more common in older adults, it can occur at any age, particularly in individuals with underlying health conditions or risk factors.

Choice B reason: Progressive kidney failure contributes to the development and severity of heart failure. Kidney function and heart function are closely related. When the kidneys are not working properly, they can contribute to fluid retention, increased blood pressure, and additional strain on the heart, leading to heart failure.

Choice C reason: The elderly patient using cocaine as a teenager and complaining of occasional anxiety is less relevant to the immediate risk factors for developing heart failure. While past cocaine use can have long-term cardiovascular effects, occasional anxiety is not a significant contributing factor to heart failure.

Choice D reason: The patient taking 20mg of losartan every day and having a potassium level of 3.8 mEq/L is relevant to managing their heart condition but does not directly address the development of heart failure. Losartan is a medication used to manage blood pressure and heart failure, and the potassium level is within the normal range.

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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

The nurse is caring for a patient with metabolic acidosis. Which laboratory findings will the nurse expect to support this diagnosis? (Select All That Apply)

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

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?

Correct Answer is B

Explanation

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