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. Perform hand hygiene before and after care: Hand hygiene is the most effective way to prevent infection transmission.
B. Implement neutropenic precautions: This is important but comes after basic infection control measures.
C. Move the client to a positive-airflow room: Positive airflow rooms are used for highly immunocompromised clients but are not the first action.
D. Ensure all visitors wear masks: This is a precautionary measure but secondary to hand hygiene.

A. Impaired Physical Mobility B. Fatigue C. Impaired Cognition D. Impaired Swallowing

Correct Answer is B

Explanation

A. Impaired Physical Mobility: although possible, it is not as common as fatigue in SLE patients.
B. Fatigue: Persistent fatigue is a hallmark symptom of SLE due to inflammation, anemia, and immune system dysregulation.
C. Impaired Cognition: While cognitive issues may occur, they are not the primary concern in most patients.
D. Impaired Swallowing: This is not a typical issue associated with SLE.

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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

A nurse is caring for a client who is immunocompromised. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

Which of the following is a common nursing diagnosis that the nurse will include in the plan of care for a patient with systemic lupus erythematosus (SLE)?

Correct Answer is B

Explanation

Which of the following conditions are classified as autoimmune diseases? (Select All that Apply.)

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