The patient is receiving blood when he suddenly complains of low back pain and develops diaphoresis and chills. The nurse should: (Select all that apply.)
a. stop the transfusion.
b. start normal saline connected to the Y tubing.
c. notify the physician.
d. start normal saline using new IV tubing.
A, C, D
If signs of a transfusion reaction occur, stop the transfusion, start normal saline with new primed tubing directly to the ventricular assist device (VAD) at the keep-vein-open rate (KVO), and notify the physician immediately.
You might also like to view...
While trying to inform a five-year-old girl about what will occur during an upcoming CT scan, the nurse notices that the child is engaged in a collective monologue, talking about a new puppy. The nurse's best response would be:
1. "You must be so excited to have a new puppy! They are so much fun. Now let me tell you again about going downstairs in a wheelchair to a special room." 2. "Please stop talking about your puppy. I need to tell you about your CT scan." 3. "I'll come back when you are ready to talk with me more about your CT scan." 4. Ignore the child's responses and continue discussing the procedure.
When examining the skin of a client who is dehydrated due to fluid losses from the gastrointestinal tract, which of the following would be most important?
A) Checking if the skin is discolored B) Checking if the mucous membranes are dry C) Examining the sclera if it is yellow D) Observing for distended abdominal veins
Which information would be most important to a nurse assessing a patient's motivation to change behavior associated with maladaptive eating regulation responses?
a. The number, on a scale of 1 to 10, that reflects the patient's desire for treatment b. The name of a support person the patient identifies for emotional support c. The disadvantages the patient identifies as resulting from the maladaptive behavior d. The reasons the patient identifies as the factors that originally caused the maladaptive behavior
A client asks the nurse what pulmonary stenosis means. Which information should the nurse provide the client?
A. Narrowing between the pulmonary artery and the right ventricle. B. Narrowing between the pulmonary vein and left atrium. C. Narrowing between the pulmonary artery and left ventricle. D. Narrowing between the pulmonary vein and the right atrium.