The client is receiving a unit of packed red blood cells. Fifteen minutes into the infusion, the client is cyanotic and complains of chest pain. What is the nurse's best first action?
A. Administer oxygen.
B. Stop the transfusion.
C. Call the emergency team.
D. Increase the infusion flow rate.
B
It is most likely that the client is having a hemolytic transfusion reaction. The infusion should be stopped immediately, even before administering oxygen or calling the emergency team, to pre-vent a more severe reaction.
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As a member of the rehabilitation team, the nurse is conscious of the need to perform the nursing role in collaboration with the other members of the team
Which of the following variables has the greatest bearing on the nurse's choice of actions and interventions during rehabilitative care? A) The skills of the other members of the team B) The circumstances of the patient C) The desires of the patient's family D) The nurse's education and experience level
A group of nurses are concerned about the chronic understaffing and mandatory overtime requirements of their state's hospitals. How could this group best help solve this issue?
1. Advise nurses to go home after their assigned shift instead of working overtime. 2. Talk to state legislatures about establishing staffing ratios. 3. Lobby for legislation supporting safe staffing measures. 4. Develop policies whereby nurse managers are the only ones required to work overtime.
A client informs the nurse he is having pleuritic pain. Before documenting this complaint, the nurse should verify if the pain:
A) increases with expiration. B) is constant along the costal borders. C) increases with deep breathing. D) subsides when client coughs.
Which assessment is most important to measure or perform before administering the first dose of amitriptyline (Elavil) to a patient?
a. Heart rate and rhythm b. Core body temperature c. Level of consciousness d. Blood pressure in the sitting position