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 C

Explanation

Choice A reason: Potassium supplements can actually be important for patients on diuretic therapy, especially if they are taking loop diuretics like furosemide, which can cause potassium loss. However, it is important to monitor potassium levels and follow the physician's guidance on supplement use.

Choice B reason: Instructing the patient to take diuretics at bedtime is not recommended. Diuretics should be taken in the morning to avoid frequent urination during the night, which can disrupt sleep.

Choice C reason: Notifying the physician if weight increases by three pounds in one week is a key instruction for patients with heart failure. Rapid weight gain can indicate fluid retention and worsening heart failure, requiring prompt medical evaluation and adjustment of treatment.

Choice D reason: Administering diuretics in the morning and notifying the physician of decreased urine output is important, but the focus on notifying the physician about significant weight gain provides a more specific and actionable guideline for managing heart failure.

A. Administer platelet transfusion immediately. B. Monitor the patient for signs of bleeding and educate about bleeding precautions. C. Administer aspirin to reduce the risk of clot formation. D. Encourage the patient to engage in regular physical exercise to improve circulation.

Correct Answer is B

Explanation

Choice A reason: Administering a platelet transfusion immediately is not indicated for a platelet count of 45,000/mm³. While this is below the normal range, it is not critically low. Platelet transfusions are typically reserved for patients with life-threatening bleeding or extremely low platelet counts.

Choice B reason: Monitoring the patient for signs of bleeding and educating about bleeding precautions is the appropriate intervention. Patients with thrombocytopenia are at an increased risk of bleeding, and it is essential to educate them on how to minimize this risk, such as avoiding activities that can cause injury, using a soft toothbrush, and avoiding over-the-counter medications that can affect platelet function.

Choice C reason: Administering aspirin to reduce the risk of clot formation is incorrect. Aspirin is an antiplatelet agent that can increase the risk of bleeding in patients with thrombocytopenia. It should be avoided unless specifically prescribed for another condition with close monitoring.

Choice D reason: Encouraging the patient to engage in regular physical exercise to improve circulation is not appropriate in this context. While physical activity is generally beneficial, it should be done with caution in patients with thrombocytopenia to avoid injury and bleeding. The focus should be on safety and bleeding precautions.

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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?

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Naxlex Comprehensive Predictor Exams

The nursing students are preparing a care plan for a patient with heart failure. The patient will be prescribed diuretic therapy after discharge. What evidence-based instructions will the nurse include in this plan?

Correct Answer is C

Explanation

The nurse is caring for a patient with thrombocytopenia who has a platelet count of 45,000/mm³. What nursing intervention will the nurse implement to manage this condition?

Correct Answer is B

Explanation

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