The nurse administers blood to the patient and observes that the patient has tachycardia, chills, and lower back pain. Which should the nurse implement first?
a. Notify the healthcare provider.
b. Notify the blood bank.
c. Complete the vital signs.
d. Remove the intravenous (IV) tubing.
D
Once the nurse suspects a transfusion reaction, he or she immediately stops the infusion so the patient receives no additional blood from the current bag and quickly primes different IV tubing with saline solution. He or she uses this to replace the blood tubing but retains the blood and the tubing for the blood bank. He or she completes the vital signs and notifies the healthcare provider and the blood bank. Stopping the infusion is the priority to limit the transfusion reaction as much as possible.
You might also like to view...
The nurse is completing the discharge teaching of a young first-time mother. Which statement requires immediate intervention?
1. "I will put my baby to bed with his bottle so he doesn't get hungry during the night." 2. "My baby will probably have a bowel movement each breastfeeding, and will wet often." 3. "Nursing every 1½–2 hours is normal, for a total of 8–12 feedings every day." 4. "I will drink yarrow tea from my grandmother to prevent my milk from coming in."
The client with suspected mitral valve prolapse asks the nurse about tests that will be done to confirm the diagnosis. Which is the best response by the nurse?
A) "A halter monitor will be used to confirm diagnosis." B) "An echocardiogram along with clinical symptoms will assist in diagnosis." C) "A chest x-ray will reveal a prolapse if present." D) "An ECG that presents a notched P wave will assist with diagnosis."
A client, scheduled for intestinal surgery, will most likely not have which of the following interventions during the preoperative period?
a. Administration of enemas until clear the morning of the surgery b. Administration of antibiotics c. Allowing no food or drink after midnight d. Application of pneumatic compression devices
A score of 52 on the Barthel Index indicates which of the following?
A) Patient has minimal dementia. B) Patient's respiratory effort is compromised. C) Patient has decreased ROM. D) Patient needs assistance with activities of daily living (ADLs).