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Practice Question

A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?

Answer Choices:

Correct Answer:

Stop the blood transfusion.

Rationale:

🔷 Stopping the transfusion is the priority when a transfusion reaction is suspected, as it prevents further infusion of potentially harmful or incompatible blood products.

🔷 Immediate cessation minimizes the risk of complications like hemolysis or anaphylaxis, which can quickly become life-threatening.

🔷 This action allows time for the nurse to assess the client's condition and notify the provider for further evaluation.

🔷 It also ensures that the reaction can be properly documented and investigated, including sending the blood bag and tubing to the lab.

🔷 Rapid intervention is essential to maintain patient safety and begin supportive treatment if needed.

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This question is from HESI-RN College Exit~2024 which contains 61 questions.

More Questions from This Exam
A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

Answer Choices:

A. Advance from clear liquids as tolerated.
B. Cefazolin 1 gram IV every 6 hours.
C. Straight catheterization if unable to void.
D. Complete blood cell count (CBC) in the morning.
After the nurse witnesses a preoperative client signing the surgical consent form, the nurse signs the form as a witness. Which is the legal implication of the nurse's signature on the client's surgical consent form? Select all that apply.

Answer Choices:

A. Verifies that the client understands the procedure that is being performed.
B. The client is competent to sign the consent without impairment of judgment.
C. The client voluntarily grants permission for the procedure to be done.
D. The surgeon has explained to the client why the surgery is necessary.
E. The client understands the risks and benefits associated with the procedure.
The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Answer Choices:

A. A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB).
B. A female adolescent admitted with multiple genital herpes simplex II lesions.
C. Twin siblings admitted with scarlet fever that is complicated with pneumonia.
D. An older client with scabies who is admitted from an extended care facility.
The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care?

Answer Choices:

A. Assess the serum potassium level every 4 hours.
B. Evaluate glucose levels before and after meals.
C. Monitor and document strict intake and output.
D. Obtain a 12-lead electrocardiogram daily.
From Exam
HESI-RN College Exit~2024

61 Questions

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Question Details
  • Category: RN Nursing Exam(s)
  • Subcategory: HESI-Exit Exam(s)
  • Domain: HESI Exit Exam(s)~2024
  • Answer Choices: 5
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