Author Question: The client has severe anemia and will be receiving blood transfusions. The nurse prepares and begins ... (Read 52 times)

audie · **on:** Jul 22, 2018

The client has severe anemia and will be receiving blood transfusions. The nurse prepares and begins the infusion. Ten minutes after the infusion has begun, the client develops tachycardia, chills, and low back pain.

After stopping the transfusion, which of the following actions should the nurse take next? a. Administer an antipyretic.
b. Begin an infusion of epinephrine.
c. Run normal saline through the blood tubing.
d. Obtain and send a urine specimen to the lab.

Question 2

In the structural assessment of the family, the nurse determines which one of the following?

a. How household tasks are shared among the family members
b. The stage of life at which the family finds itself presently
c. The emotional links between family dyads
d. Which factors influence the roles and behaviours within the family

kjo;oj · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

D
After stopping the blood transfusion, the nurse should obtain and send a urine specimen to the lab to determine the presence of hemoglobin as a result of RBC hemolysis.
In an acute hemolytic reaction, management of the reaction does not include the administration of an antipyretic.
The nurse does not begin an infusion of epinephrine. The nurse should be prepared to administer emergency drugs, such as diuretics, per the physician's order.
The nurse should not turn off the blood and simply turn on the normal saline that is connected to the Y-tubing set. This would cause blood remaining in the Y-tubing to infuse into the client. Even a small amount of mismatched blood can cause a major reaction. The nurse should run normal saline directly into the IV line (not through the blood tubing).

Answer to Question 2

D
In the structural assessment, the nurse identifies birth order, gender, and distance in age between siblings, since these may influence roles and behaviours within the family.
The sharing of household tasks can be assessed in the functional assessment, more precisely in-strumental functioning.
In the developmental assessment, the nurse will assess the phase of the family's developmental life cycle.
The emotional ties between family dyads can be assessed under subsystems (structural assess-ment) and also under alliances and coalitions (expressive functioning).