Practice Quiz

NCLEX-PN

Category - Physiological Adaptation

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The nurse is monitoring a client who is undergoing a blood transfusion. The nurse notices that the client is having difficulty breathing. The respiratory rate is assessed at 24 breaths/min. The client is afebrile and no rashes are noted. What should the nurse do first?
  1. Stop the transfusion and call the physician immediately
  2. Check the IV flow rate and elevate the head of bed
  3. Do nothing. The client is afebrile and there are no rashes noted
  4. Give oxygen per nasal cannula
Explanation
Answer: B - Difficulty breathing may indicate fluid overload. Client is afebrile and does not have rashes, therefore transfusion reaction may be ruled out. Option A is unnecessary unless transfusion reaction occurs. Option C is incorrect. Option D comes later.
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