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

Explanation

Choice A reason: The patient being increasingly drowsy and hard to arouse is an urgent finding that should be reported immediately. This condition may indicate intracranial bleeding or other severe complications related to extremely low platelet count (10,000/mm³) in idiopathic thrombocytopenic purpura (ITP). Immediate medical intervention is required to prevent further deterioration.

Choice B reason: Red, raised purpura on the patient's feet and hands is a concerning finding indicative of significant thrombocytopenia, but it is not as immediately life-threatening as decreased consciousness. It should still be monitored and managed, but the priority is the patient's level of consciousness.

A. Kussmaul breathing B. Abdominal pain C. Positive Trousseau sign D. Decreased heart rate E. Confusion

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.

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

Correct Answer is A

Explanation

The nurse is caring for a patient with diabetic ketoacidosis (DKA). What clinical manifestations will the nurse anticipate the patient to present? (Select All That Apply)

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

Explanation

The nurse is teaching a patient who is experiencing a sickle cell crisis about non-pharmacological interventions to help alleviate symptoms. Which of the following interventions will the nurse recommend?

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The nurse is caring for a patient with hyperosmolar hyperglycemic syndrome. The patient is receiving intravenous fluids of normal saline with 20 mEq of potassium chloride and a continuous insulin infusion. Which finding will indicate to the nurse that the treatment is effective?

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The nurse is discussing microvascular complications of diabetes with a patient. What topics will the nurse include in the discussion?