A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?
Stop the transfusion.
Administer diphenhydramine.
Obtain vital signs.
Notify the registered nurse.
The Correct Answer is A
A. Stop the transfusion: Stopping the transfusion is the priority action to prevent further exposure to the antigen causing the reaction.
B. Administer diphenhydramine: Administering diphenhydramine is an appropriate intervention for allergic reactions, but stopping the transfusion should be done first to halt the reaction source.
C. Obtain vital signs. Obtaining vital signs is important but should follow stopping the transfusion to address the immediate risk of reaction.
D. Notify the registered nurse: Notifying the registered nurse is necessary but comes after stopping the transfusion to immediately mitigate the reaction.
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Correct Answer is B
Explanation
A. Report fever to MD ASAP: While fever in any immunocompromised patient should be reported, it does not directly address precautions related to low platelet counts and bleeding risks.
B. Use a soft toothbrush with oral care: With a low platelet count, the patient is at risk for bleeding. Using a soft toothbrush minimizes the risk of gum injury and bleeding, a critical safety measure for thrombocytopenic patients.
C. Drink hot liquids TID: Hot liquids are not recommended as they may cause mouth or esophageal burns, increasing bleeding risk if the mucosa is damaged. Tepid or cold fluids are safer.
D. Recommend straight edge razor for shaving: Patients with low platelets should use an electric razor to avoid cuts, as any bleeding is harder to control in thrombocytopenic individuals.
Correct Answer is A
Explanation
A. Results indicate the presence of Reed Sternberg cells: Reed-Sternberg cells are a defining characteristic of Hodgkin disease, a type of lymphoma. Their presence in biopsy samples confirms the diagnosis, distinguishing Hodgkin disease from other types of lymphomas and leukemias.
B. The patient is cyanotic: Cyanosis, or bluish skin discoloration due to low oxygen levels, is not a common sign of Hodgkin disease. It may occur in advanced disease due to respiratory compromise but is not a defining characteristic.
C. The patient is complaining of excessive thirst and hunger: Excessive thirst and hunger are more characteristic of diabetes mellitus, not Hodgkin disease. These symptoms are unrelated to the lymphatic involvement seen in Hodgkin disease.
D. Results indicate the presence of the Philadelphia chromosome: The Philadelphia chromosome is a genetic abnormality associated with chronic myelogenous leukemia (CML), not Hodgkin disease. Its presence suggests a different hematologic malignancy.