Practice Question
A client is receiving a unit of packed red blood cells (PRBCs). Which is the first action the practical nurse (PN) should take if the client begins to shake and reports feelings of nausea and vomiting?
Answer Choices:
Correct Answer:
Stop the blood infusion.
Rationale:
🛑 Shaking, nausea, and vomiting during a blood transfusion are potential signs of a transfusion reaction, which can be life-threatening.
🛑 The first and most critical action is to immediately stop the transfusion to prevent further exposure to the incompatible or contaminated blood product.
🛑 After stopping the infusion, the PN should maintain IV access with 0.9% sodium chloride, notify the healthcare provider, and monitor vital signs.
🛑 Further actions include returning the blood bag and tubing to the lab and completing transfusion reaction protocols.
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This question is from Hesi Specialiaty-LPN Med Surg Exam. which contains 57 questions.
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Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN HESI Exams
- Domain: Med-Surgical
- Answer Choices: 4