A patient had an acute intravascular hemolytic reaction to a blood transfusion. After discontinu-ing the blood transfusion, what is the nurse's next action?
a. Run normal saline through the existing tubing.
b. Start normal saline at TKO rate using new tubing.
c. Discontinue the IV catheter.
d. Return the blood to the blood bank.
ANS: B
The nurse should first attach new tubing and begin running in normal saline at a rate to keep the vein open, in case any sorts of medications need to be delivered through that IV site. The exist-ing tubing should not be used because that would infuse the blood in the tubing into the patient. It is necessary to preserve the IV catheter in place for IV access to treat the patient. After the pa-tient has been assessed and stabilized, the blood can be returned to the blood bank.
You might also like to view...
The nurse is caring for a 3-year-old boy with encephalitis. Which of the following actions would demonstrate atraumatic care?
A) Providing EMLA (lidocaine) prior to lumbar puncture B) Having his anxious mother stay in the waiting room C) Explaining, in medical terms, what will happen D) Starting the child's IV in his room
Allopurinol (Zyloprim) has been ordered for a patient receiving treatment for gout. The nurse caring for this patient knows to assess the patient for bone marrow suppression, which may be manifested by which of the following diagnostic findings?
A) Hyperuricemia B) Increased erythrocyte sedimentation rate C) Elevated serum creatinine D) Decreased platelets
A client who was raped tells the nurse that she must not get pregnant. Which response by the nurse is appropriate?
A) "The baby could always be given up for adoption." B) "You will not know for sure for at least a few more days." C) "There is a medication called Plan B, which is emergency contraception." D) "Are you sure the rapist did not use a condom?"
A nurse gathers information about the condition of homes, size of lots, neighborhood hangouts, road conditions, and modes of transportation. Which method of data collection is being used?
a. Participant observation b. Windshield survey c. Focus group d. Informant interviews