The nurse is providing care for a patient who is receiving a blood transfusion. Pre-transfusion vital signs were blood pressure (BP), 144/78 mm Hg; temperature (T), 98.4°F; pulse (P), 86; respirations (R), 14
Now, approximately an hour after the transfusion was initiated, the patient's vital signs are BP, 168/92 mm Hg; P, 98; R, 20. Next, the nurse should
1. Record the vital signs.
2. Listen to the patient's breath sounds.
3. Notify the physician.
4. Slow the transfusion rate.
ANS: 2
You might also like to view...
A 40-year-old patient has a body mass index that classifies him as being severely obese. For several months, the patient has been working with an interdisciplinary team in an effort to lose weight, but he has experienced nominal success
His physician has proposed the use of orlistat, and the nurse has conducted appropriate health education. What statement by the patient indicates a need for further teaching? A) "They explained to me that I have to take the medicine with my meals." B) "I'm excited that I won't have to cut down on my favorite fried foods anymore." C) "It still amazes me that you can take a pill that will actually help you lose weight." D) "If I understand correctly, these pills will help me lower my cholesterol as well as lose weight."
The nurse should notify the primary health care provider when which of the following occur while a client is receiving an antihypertensive? Select all that apply
A) Weight gain of 2 lb or more per day B) Headache C) Edema D) Insomnia E) Sedation
The nurse is preparing an educational program regarding adverse drug reactions (ADR). What information should the nurse include? Select all that apply.
1. Older adults are more likely to have adverse drug events. 2. Drug side effects that are serious are considered ADRs. 3. Adverse drug reactions are handled on an outpatient basis. 4. Adverse drug reactions are often due to anticoagulants or antidiabetics. 5. Reactions can occur from drug-drug interactions and polypharmacy.
An 18-month-old child develops an urticarial reaction after a transfusion. The prescriber orders intravenous promethazine (Phenergan). What will the nurse do?
a. Give the medication as ordered. b. Monitor the child for bronchoconstriction. c. Question the order. d. Request an order to give the drug orally.