Fifteen minutes after the infusion of packed red blood cells (RBCs) has begun, the patient complains of difficulty breathing and chest tightness. The most appropriate initial action for the nurse to take is:
A) Notify the patient's physician.
B) Stop the transfusion immediately.
C) Remove the patient's intravenous access.
D) Assess the patient's chest sounds and vital signs.
Ans: B
Feedback: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the patient's vital signs, and notify the physician. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected.
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The measures the nurse caring for the client should incorporate into the plan of care include (more than one answer may be correct) A. maintaining arm-length, one-on-one nursing observation around the clock. B. allowing no glass or metal on meal trays. C. keeping client within visual range while he or she is awake. Check every 15 to 30 minutes while the client is sleeping. D. checking client whereabouts every 15 minutes and make frequent verbal contacts. E. checking whereabouts every hour. Make verbal contact at least three times each shift. F. removing all potentially harmful objects from the client's possession.
The nurse is developing a concept care map for a client with multiple medical problems. What would the nurse take as the first step in developing and using a concept care map?
A) Assessment B) Assessment/Diagnosis C) Diagnosis/Planning D) Planning/Implementation
A patient complains of chronic insomnia and reports being tired of being tired all the time. The patient is reluctant to try pharmacologic remedies and asks the nurse what to do. What will the nurse suggest?
a. "Eat a large meal in the evening to induce drowsiness." b. "Get out of bed for a while if you can't fall asleep." c. "Have a glass of wine at bedtime to re-lax." d. "Take a short nap early in the afternoon every day."
Because risk for childbirth complications may be revealed, nurses should know that the PMI of the FHT is:
1. usually directly over the fetal abdomen. 2. in a vertex position, heard above the mother's umbilicus. 3. heard lower and closer to the midline of the mother's abdomen as the fetus des-cends and rotates internally. 4. in a breech position, heard below the mother's umbilicus.