Practice Question
A nurse is caring for a client who is receiving one unit of packed red blood cells (RBCs) due to intraoperative blood loss. The client reports chills and back pain, and their blood pressure is 80/64 mm Hg. What should be the nurse's first action?
Answer Choices:
Correct Answer:
Stop the infusion of blood.
Rationale:
🍃 The combination of chills, back pain, and hypotension (BP 80/64 mm Hg) indicates a severe transfusion reaction.
🍃 The first and most critical action is to stop the transfusion to prevent further antigen exposure.
🍃 Only after stopping should the nurse notify the provider, obtain specimens, and monitor vitals.
🍃 Early response prevents escalation to hemolysis and multi-organ damage.
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This question is from RN ATI MedSurg Exam III which contains 67 questions.
More Questions from This Exam
Which of the following assessments would be most useful in determining a patient's genetic risk for breast cancer?
Answer Choices:
A. Do you perform self-examinations for breast cancer?
B. Have you ever had a suspicious mammogram?
C. Are you aware of your BRCA (breast cancer gene) status?
D. Have you ever noticed dimpling during a breast self-exam?
A nurse is caring for a client who is experiencing chills and back pain during a blood transfusion. What should be the nurse's priority action?
Answer Choices:
A. Assess the client's skin for a rash.
B. Notify the provider.
C. Cover the client with a blanket.
D. Stop the transfusion.
A nurse is caring for a client diagnosed with systemic scleroderma five years ago. The nurse plans to assess the client to document the disease's progression. In addition to skin changes, which of the following findings should the nurse expect?
Answer Choices:
A. Periorbital edema.
B. Excessive salivation.
C. Finger contractures.
D. Thinning of the skin.
A nurse is educating a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?
Answer Choices:
A. "I should avoid the use of tanning booths."
B. "I should use sunscreen even on cloudy days."
C. "l should check my skin monthly for any changes."
D. "Eating a high fiber diet will reduce my risk for developing skin cancer."
A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?
Answer Choices:
A. Blood
B. Parasites
C. Steatorrhea.
D. Yeast
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI MedSurg
- Answer Choices: 4