A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to
a. administer oxygen therapy at a high flow rate.
b. obtain a urine specimen to send to the laboratory.
c. notify the health care provider about the symptoms.
d. disconnect the transfusion and infuse normal saline.
ANS: D
The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.
You might also like to view...
When a 90-year-old resident in a long-term care facility becomes progressively confused and irritable, the nurse should:
a. request an order for a urinalysis. b. hold antihypertensive medications. c. assess for fecal impaction. d. notify the charge nurse.
When the urinary bladder is removed, a new pathway is needed for urine to exit the body. The new pathway is called a:
a. Urinary diversion b. Bladder diversion c. Renal pathway d. Renal tubule
If there is a very strong effect when two drugs are taken in combination, even though one of the drugs by itself has no effect and the other by itself has only a weak effect, then the combination effect is called
A. additive B. subtractive C. synergistic D. potentiation
A newly diagnosed type 1, insulin-dependent diabetic with good blood sugar control at 20 weeks' gestation asks how the diabetes will affect the baby. How should the nurse respond?
1. "Your baby may be smaller than average at birth." 2. "Your baby will probably be larger than average at birth." 3 "Your baby might have high blood sugar for several days." 4. "As long as you control your blood sugar, your baby will not be affected at all."