Practice Quiz

CCRN Critical Care Nursing

Category - Adult

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A nurse is taking care of a patient who has Hemoglobin of 4.2. The nurse hung the second unit of packed red blood cells five minutes ago and the patient is suddenly flushed, breathing rapidly. The monitor shows a heart rate of 150. What is the first thing the nurse should do?
  1. Apply oxygen via a non-rebreather mask to the patient.
  2. Administer antihistamines or beta 2 agonists.
  3. Call the rapid response team.
  4. Discontinue the blood.
Explanation
Answer: D - The first thing the nurse should do when a patient shows signs of a reaction are to find the potential cause of the reaction and stop it. After that, calling the rapid response team, administering oxygen and administering antihistamines or beta 2 agonists would be appropriate.
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