the nurse is assessing a client who has just received a blood transfusion the client reports chills and back pain what is the nurses priority action
Logo

Nursing Elites

HESI LPN

Adult Health Exam 1

1. The nurse is assessing a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?

Correct answer: C

Rationale: The correct answer is C: Stop the transfusion immediately. Chills and back pain are indicative of a possible transfusion reaction, which is a critical situation. Stopping the transfusion is crucial to prevent further complications and ensure the client's safety. Slowing the rate of transfusion (Choice A) is not sufficient in this case as immediate action is required. Administering an antipyretic (Choice B) may help with fever but does not address the potential severe reaction. Notifying the healthcare provider (Choice D) can be done after stopping the transfusion, but the priority is to halt the infusion to prevent harm.

2. During a bed bath, the nurse observes that a client's IV site is red and swollen. What should the nurse do first?

Correct answer: C

Rationale: The correct first action when a nurse observes a red and swollen IV site during a bed bath is to notify the physician. This is crucial because prompt reporting allows for immediate intervention to prevent further complications. Discontinuing the IV (Choice A) should only be done under the physician's guidance to avoid any adverse effects and ensure proper care. Applying a warm compress (Choice B) may not address the underlying issue and could potentially worsen the situation if the cause is an infection or infiltration. Documenting the site's appearance and continuing the bath (Choice D) without immediate action might delay necessary treatment, leading to potential complications.

3. A client reports feeling anxious and having trouble sleeping lately. What non-pharmacological intervention should the nurse suggest first?

Correct answer: C

Rationale: The correct non-pharmacological intervention the nurse should suggest first for a client experiencing anxiety and sleep issues is practicing relaxation techniques before bed. Relaxation techniques like deep breathing, progressive muscle relaxation, or mindfulness meditation can help reduce anxiety levels and promote better sleep naturally. Starting an exercise program (Choice A) can be beneficial but may not provide immediate relief for anxiety and sleep problems. Keeping a sleep diary (Choice B) can help identify patterns but does not directly address anxiety. Using sleep-inducing medications (Choice D) should be considered only after non-pharmacological interventions have been tried.

4. A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make?

Correct answer: B

Rationale: The correct response for the nurse in this situation is to ask for a description of what happened during the night. This allows the nurse to gather specific information about the care provided and address the complaint appropriately. Choice A is incorrect because dismissing the concern by stating that all staff are doing their best does not address the specific complaint. Choice C is not the best immediate response as the charge nurse should first gather information before escalating the issue to the nurse manager. Choice D is incorrect as it focuses on reassurance without addressing the reported issue.

5. A client with a history of seizures is being discharged home. Which instruction is most important for the nurse to provide?

Correct answer: A

Rationale: The most important instruction for a client with a history of seizures being discharged home is to take their medication as prescribed. Consistent and timely intake of anti-seizure medication is vital in managing seizures and preventing episodes. While instructions like avoiding driving until the condition is stable, keeping a seizure diary, and avoiding alcohol consumption are important, none are as critical as ensuring proper medication adherence to control seizures effectively. Failure to take prescribed medications can lead to breakthrough seizures, compromising the patient's safety and seizure control.

Similar Questions

A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape to anchor the shield most effectively?
A client with hypothyroidism is being treated with levothyroxine (Synthroid). What is the most important information for the nurse to provide to the client?
The client is being educated by the nurse about the side effects of prednisone. Which side effect should the client be instructed to report immediately?
The client with newly diagnosed peptic ulcer disease (PUD) is being taught about lifestyle modifications. Which instruction should be included?
A new mother is at the clinic with her 4-week-old for a well-baby check-up. The nurse should tell the mother to anticipate that the infant will demonstrate which milestone by 2 months of age?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses