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 C
Explanation
A. Intense abdominal pain: While abdominal pain may occur in some conditions related to anemia, it is not a typical finding in anemia due to blood loss.
B. Respiratory depression: Respiratory depression is not commonly associated with anemia and would more likely indicate issues with central nervous system depression or drug side effects.
C. Dyspnea on exertion: Dyspnea on exertion is common in clients with anemia because of the decreased oxygen-carrying capacity of the blood, leading to tissue hypoxia. Anemia results in decreased hemoglobin levels, reducing the body’s ability to deliver adequate oxygen, particularly during physical activity.
D. Bradycardia: Anemia typically causes tachycardia (increased heart rate) rather than bradycardia, as the body compensates for low oxygen levels by increasing cardiac output.
Correct Answer is B
Explanation
A. Initiate a 2 L/day fluid restriction: Hydration is crucial in sickle cell crisis to prevent further sickling and reduce blood viscosity. A fluid restriction would worsen the crisis.
B. Assist with administering a blood transfusion: Blood transfusions are commonly given during sickle cell crisis to manage anemia and reduce the concentration of sickled cells, which can improve oxygen delivery and relieve pain.
C. Withhold opioids to avoid dependence: Pain management, including opioids if needed, is essential during a sickle cell crisis. The risk of dependence is secondary to controlling acute pain.
D. Encourage exercise: Rest is recommended during a crisis to reduce oxygen demand and prevent further sickling. Exercise would increase oxygen needs, worsening the crisis.