Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
56. A client with a history of GI bleeding is admitted with complaints of fatigue, weakness, and shortness of breath. Hgb is 7.4 mg/dL, T 97.8°F, BP 86/45 mm Hg, P 118, and R 22. Two units of packed RBCs are ordered. As a nurse begins the blood transfusion, the client suddenly complains of chills and chest pain. Which actions should be taken by the nurse? Select all that apply.
. Taking the client's vital signs.
. Giving acetaminophen as ordered.
. Stopping the blood transfusion.
. Infusing normal saline to keep vein open.
. Disposing of blood product in biohazard container.
. Sending blood product to lab for analysis.
Test-Taking Tip
Note that Answers 5 and 6 are contradictory. Select Answer 6—keep rather than dispose of the blood product. With each option, ask if the statement is a true or false action with a transfusion reaction.
Content Area: Adult Health, Hematological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Pharmacological and Parenteral Therapies/Blood and Blood Products
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
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Answer 1 is correct because a transfusion reaction can lead to anaphylactic shock and life-threatening vasodilation and hypotension. Answer 2 is incorrect because treating pain or a fever is not the priority. Answer 3 is correct because the client should not receive any more blood, which is the source of the antigen that is causing the allergic response. Answer 4 is correct because a patent IV may be needed for emergency treatment. Answer 5 is incorrect because the blood needs to be returned to the laboratory, not disposed of. Answer 6 is correct because the reason for the allergic reaction needs to be determined.