The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?

Remove the client's IV access.

Assess the client's chest sounds and vital signs

Notify the client's healthcare provider.

Stop the transfusion immediately.

Answer and Explanation

The Correct Answer is D

A. Remove the client's IV access:

Removing the client's IV access is not the most appropriate initial action when a client experiences difficulty breathing and severe chest tightness during a transfusion. While it's important to discontinue the infusion, the immediate priority is to stop the transfusion itself to prevent further reaction and assess the client's condition.

B. Assess the client's chest sounds and vital signs:

This choice is the correct answer. After stopping the transfusion, the nurse should assess the client's respiratory status by listening to chest sounds for any wheezing or crackles, as well as checking vital signs such as oxygen saturation, respiratory rate, blood pressure, and heart rate. These assessments help evaluate the severity of the reaction and guide further interventions.

C. Notify the client's healthcare provider:

Notifying the healthcare provider is an essential step, but it typically follows the immediate action of stopping the transfusion and assessing the client's condition. The healthcare provider needs to be informed promptly about the client's condition, transfusion reaction, and the actions taken for further guidance and orders.

D. Stop the transfusion immediately:

This is the initial and most critical action when a client experiences signs of a transfusion reaction such as difficulty breathing and severe chest tightness. Stopping the transfusion promptly helps prevent the reaction from worsening and allows for immediate assessment and intervention to ensure client safety.

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Correct Answer is C

Explanation

A. 120/80 mm Hg or lower:

This blood pressure range is considered normal or optimal for most adults. However, for individuals diagnosed with hypertension, the goal is typically to reduce blood pressure to below 140/90 mm Hg, as maintaining normal blood pressure is not considered a goal for hypertension treatment unless specifically indicated based on individual circumstances.

B. Average of two BP readings of 150/80 mm Hg:

A blood pressure reading of 150/80 mm Hg is elevated and indicates hypertension, especially if consistently elevated across multiple readings. The goal of hypertension treatment is to lower blood pressure to below 140/90 mm Hg, so an average of 150/80 mm Hg would not be considered the goal of treatment.

C. 140/90 mm Hg or lower:

This blood pressure range is commonly recommended as the goal of treatment for individuals with hypertension who otherwise enjoy good health. It represents a balance between effective blood pressure control and minimizing the risk of side effects or complications associated with overly aggressive treatment.

D. 156/96 mm Hg or lower:

While a blood pressure reading of 156/96 mm Hg is elevated and indicates hypertension, the goal of treatment is typically to reduce blood pressure to below 140/90 mm Hg rather than targeting a specific numeric value below 156/96 mm Hg.

A. Take the medication with milk to increase absorption. B. Take the medication on an empty stomach C. Eat foods high in fiber while on this medication. D. Report stools that are dark in color immediately. E. Eating citrus fruit and juices are recommended with meals.

Correct Answer is ["B","C","D","E"]

Explanation

A. Take the medication with milk to increase absorption:

This statement is incorrect. Taking ferrous sulfate with milk or dairy products is not recommended as they can decrease iron absorption. It's advisable to take iron supplements with water or juice, preferably on an empty stomach or with a small amount of food.

B. Take the medication on an empty stomach:

This statement is partially correct. While taking ferrous sulfate on an empty stomach can enhance absorption, some individuals may experience gastrointestinal discomfort or irritation. Therefore, it's often recommended to take iron supplements with a small amount of food to minimize potential side effects.

C. Eat foods high in fiber while on this medication:

This statement is generally correct. Consuming foods high in fiber can help prevent constipation, which is a common side effect of iron supplements. Including fiber-rich foods in the diet, such as fruits, vegetables, whole grains, and legumes, can promote regular bowel movements.

D. Report stools that are dark in color immediately:

This statement is correct. Dark or black stools can indicate the presence of digested blood, which may occur due to iron supplementation. It's important to report such changes to the healthcare provider promptly for further evaluation.

E. Eating citrus fruit and juices are recommended with meals:

This statement is correct. Citrus fruits and juices, such as oranges, grapefruits, and lemon juice, contain vitamin C, which can enhance iron absorption. Consuming vitamin C-rich foods or drinks along with iron supplements can help improve iron uptake by the body.

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The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning the care of a client who has been diagnosed with hypertension but who otherwise enjoys good health. When assessing the response to an antihypertensive drug regimen, what blood pressure would be the goal of treatment?

Correct Answer is C

Explanation

A client is prescribed ferrous sulfate 325 mg BID. What education should the nurse provide about this medication? (Select All that Apply.)

Correct Answer is ["B","C","D","E"]

Explanation

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