Author Question: A client complains of a headache and chills during a blood transfusion. Which one of the following ... (Read 47 times)

bucstennis@aim.com · **on:** Jul 22, 2018

A client complains of a headache and chills during a blood transfusion. Which one of the following actions should the nurse take immediately?

a. Check the vital signs.
b. Stop the blood transfusion.
c. Slow the rate of blood flow.
d. Notify the physician and blood bank personnel.

Question 2

The client comes to the emergency department after having been in the sun for an extended period. The nurse also determines that the client is taking a diuretic. Heatstroke is suspected. Which of the following does the nurse observe for?

a. Diaphoresis
b. Confusion
c. Temperature of 36C
d. Decreased heart rate

lcapri7 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B
If a blood reaction is suspected, the nurse stops the blood transfusion immediately.
The nurse should take the client's vital signs, but the initial action should be to stop the blood transfusion.
The nurse should not slow the rate of blood flow. The nurse should stop the blood transfusion.
The nurse should first stop the blood transfusion. The nurse notifies the physician and blood bank personnel after the transfusion is stopped.

Answer to Question 2

B
Confusion is a symptom of heatstroke, along with delirium, nausea, muscle cramps, visual dis-turbances, giddiness, and even incontinence, as well as hot, dry skin.
The most important sign of heatstroke is hot, dry skin, not diaphoresis. Victims of heatstroke do not sweat because of severe electrolyte loss and hypothalamic malfunction.
A normal temperature is between 36C to 38C. With heatstroke, the client's body temperature may reach as high as 45C.
The heart rate is increased with heatstroke, not decreased.