The nurse suspects the patient is having a blood transfusion reaction. What is the FIRST action the nurse should do?

Stop the transfusion

Call the blood bank to report the reaction

Administer oxygen

Call the physician

Answer and Explanation

The Correct Answer is A

A.   Stop the transfusion: The immediate priority is to halt the infusion to prevent further exposure to the offending blood product.
B.   Call the blood bank to report the reaction: This is done after the transfusion is stopped and the patient is stabilized.
C.   Administer oxygen: Oxygen administration may be required if the patient shows signs of respiratory distress but is not the immediate first action.
D.   Call the physician: Notifying the physician is important but only after stopping the transfusion and assessing the client.

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Correct Answer is A

Explanation

A. Hemolytic transfusion reaction: Administering the wrong blood type can lead to a hemolytic transfusion reaction, where the immune system attacks the transfused red blood cells, causing serious complications.
B. Pernicious anemia: Pernicious anemia is related to a lack of intrinsic factor and vitamin B12 absorption, not blood transfusions.
C. Angioedema: Angioedema involves swelling of the skin or mucous membranes, typically due to allergic reactions, not blood transfusions.
D. Contact dermatitis: Contact dermatitis is a skin condition caused by direct contact with allergens, irritants, or chemicals, not by blood transfusions.

A. "I need to carry the Epi-pen with me at all times." B. "When my Epi-pen reaches it's expiration date. I need to get a new one." C. "Once I inject myself with my Epi-pen. I won't have to go to the hospital." D. "I need to avoid all foods that may have been exposed to peanuts."

Correct Answer is C

Explanation

"I need to carry the Epi-pen with me at all times": Individuals with severe allergies should always have an Epi-pen in case of exposure to allergens. No reinforcement needed.

"When my Epi-pen reaches its expiration date, I need to get a new one": Epi-pens have a limited shelf life, and using an expired pen may be ineffective. No reinforcement needed.

"Once I inject myself with my Epi-pen, I won't have to go to the hospital": Epinephrine provides temporary relief, but further medical evaluation is essential due to the risk of a biphasic reaction or persistent symptoms. Reinforcement needed.

"I need to avoid all foods that may have been exposed to peanuts": Strict avoidance of allergens is essential to prevent severe reactions. No reinforcement needed.

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The nurse suspects the patient is having a blood transfusion reaction. What is the FIRST action the nurse should do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse knows that it is very important when giving a patient blood to make sure it is the correct blood type to avoid which of the following conditions?

Correct Answer is A

Explanation

The nurse is educating a patient concerning use of an Epi-pen for a severe allergic reaction to peanuts. Which of the following statements, made by the patient, allows the nurse to know that the education must be reinforced?

Correct Answer is C

Explanation

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