Author Question: The nurse is monitoring a patient who is receiving a blood transfusion. Which finding(s) would lead ... (Read 131 times)

mwit1967 · **on:** Jun 25, 2018

The nurse is monitoring a patient who is receiving a blood transfusion. Which finding(s) would lead the nurse to stop the infusion? (Select all that apply.)

a. Report of chills
b. Headache
c. Back pain
d. Report of a rash
e. Fever

Question 2

The nurse is caring for a newly admitted patient with uncontrolled nausea and vomiting. The patient has a history of alcoholism and diabetes.

After receiving these orders from the health care provider, which order(s) should the nurse question? (Select all that apply.)
a. Administer 10 mg prochlorperazine ma-leate (Compazine), IM every 4 to 6 hours for nausea and vomiting.
b. Administer diphenoxylate atropine (Lo-motil), two tabs, by mouth after first oc-currence of nausea and vomiting.
c. Administer furosemide (Lasix) 40 mg by slow IV push.
d. Monitor the patient's intake and output every 4 hours.
e. Obtain patient's weight every morning and record.

fauacakatahaias · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

B, C, D, E
Headache, back pain, rash, and fever are findings that indicate a reaction to the transfusion; the transfusion should be stopped. The nurse should then infuse saline solution into the line to keep the intravenous line patent. Report of chills correlates to the infusion of the chilled blood. The transfusion is not stopped; the patient is given a blanket.

Answer to Question 2

A, B, C
A primary concern in a patient with uncontrolled vomiting includes monitoring hydration status. Intake and output and daily weights are indicators of hydration status and should be assessed. Prochlorperazine maleate (Compazine) should not be given with alcohol intake. Because the pa-tient has a history of alcoholism, it would be best to administer an antiemetic that is not con-traindicated with possible alcohol intake. Diphenoxylate atropine (Lomotil) is an antidiarrheal, not an antiemetic. Lasix is a powerful loop diuretic that would exacerbate the patient's volume depletion.