The nurse assisting with the care of a client receiving two units of blood is asked to record vital signs after the second unit is initiated
The nurse enters the room of the client, a 28-year-old female admitted following a salpingectomy secondary to an ectopic pregnancy, and finds her unconscious with weak pulse and shallow respirations. The nurse notes a rash over the exposed areas of her body. What is the nurse's priority action? 1. Attempt to revive the woman and measure vital signs.
2. Increase the rate of the blood infusion to raise her blood pressure quickly.
3. Stop the blood infusion.
4. Prepare another IV with fresh tubing, and connect to the IV site where the blood was infusing.
3
Rationale: The client is most likely having a blood transfusion reaction, and the priority intervention, before doing anything else, is to make sure that the client does not receive any more blood. After the infusion is stopped, the RN should be notified, vital signs should be recorded, and new IV solution should be hung using fresh tubing, but the first and most important priority is to stop infusing the blood that is causing the reaction.
You might also like to view...
The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle
bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex
While teaching an Asian woman about prenatal care, the nurse notes that the woman refuses to make eye contact. This is most likely due to:
a. embarrassment about the subject. b. lack of understanding. c. cultural beliefs about eye contact. d. a submissive attitude.
While bathing a patient with cancer, a nurse assessed several large new bruises on the patient's upper arms and thighs. What is the best understanding of the possible causes and the correct nurse's actions for these findings?
a. The patient must have fallen last night walking to the bathroom. Teach the pa-tient to use the call bell when assistance is needed. b. The patient may have disseminated intra-vascular coagulation. The size, shape, lo-cation, color, and tenderness must be re-ported and recorded fully. c. An intravascular fluid overload is occur-ring because of the chemotherapy. Place the patient on strict input/output (I/O) sta-tus and limit fluids. d. The patient must have had a drug-induced seizure, which caused arm and leg thrash-ing and the bruises. Report and record the findings, and pad the side rails.
A staff RN is writing an article for a prestigious nursing journal. The deadline is in 1 week, and she is feeling overwhelmed about completing her work
She is unable to keep up with home management, and she is beginning to procrastinate on the project. She also has other responsibil-ities, such as taking her elderly mother grocery shopping and to health care appointments. She is married to a busy executive and has three children, all of whom are active in high school sports. Which of the following time management strategies would be helpful (select all that apply)? a. Break the project into smaller, manageable pieces. b. Contact an elderly nurse aide helper pro-gram to assist with shopping. c. Cut extra activities out of her schedule, such as her morning walk. d. Delegate some of the household chores to her family.