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Test-Taking Strategy:Use the process of elimination, noting the strategic word “priority” in the query of the question. Use the ABCs (airway, breathing, and circulation) to identify the correct option. Review the effects of morphine sulfate if you had difficulty with this question.Level of Cognitive Ability:AnalyzingClient Needs:Physiological IntegrityIntegrated Process:Nursing Process/PlanningContent Area:PharmacologyReference:Lehne, R. (2010). Pharmacology for nursing care(7th ed., pp. 283, 284, 264). St. Louis: Saunders.Awarded 1.0 points out of 1.0 possible points.V.75.ID: 383694318A nurse discontinues infusion of a unit of packed red blood cells (RBCs) because the client is experiencing a transfusion reaction. After discontinuing the transfusion, which of the following actions does the nurse take next?
A.Removing the IV catheterB.Contacting the healthcare provider CorrectC.Changing the solution to 5% dextrose in waterD.Obtaining a culture of the tip of the catheter device removed from the clientRationale:If the nurse suspects a transfusion reaction, the transfusion is stopped and normal saline solution infused at a keep-vein-open rate pending further physician prescriptions. The nurse then contacts the physician. Dextrose in water isnot used, because it may cause clotting or hemolysis of blood cells. Normal saline solution is the only type of IV fluid that is compatible with blood. The nurse would
not remove the IV catheter, because then there would be no IV access route through which to treat the reaction. There is no reason to obtain a culture of the catheter tip; this is done when an infection is suspected. Test-Taking Strategy:Use the process of elimination, focusing on the strategic word“next.” Knowing that the IV should not be removed will assist you in the eliminationprocess. Recalling that normal saline solution is the only type of IV fluid that is compatible with blood will also help you answer correctly. To select from the remaining options, note that infection is not the concern; this will help you eliminate the option of obtaining a culture of the catheter tip. Review care of the client experiencing a transfusion reaction if you had difficulty with this question. Level of Cognitive Ability:ApplyingClient Needs:Physiological Integrity Integrated Process:Nursing Process/ImplementationContent Area:Blood administrationReference:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Critical thinking for collaborative care(6th ed.). Philadelphia: W. B. Saunders, p. 919.Awarded 1.0 points out of 1.0 possible points.W.76.ID: 383697159A client is receiving intravenous bleomycin sulfate. During administration of the chemotherapy, which of the following nursing assessments is of the highest priority?