A patient receiving a blood transfusion reports chills, lower back pain, and chest tightness. What is the nurse's first action?
Correct answer: B. Stop the transfusion and maintain venous access
- A. Slow the transfusion and observe the patient
- B. Stop the transfusion and maintain venous access
- C. Obtain a urine specimen for laboratory testing
- D. Give the prescribed antipyretic medication
Explanation
The symptoms may indicate an acute transfusion reaction, so the transfusion must be stopped immediately. Venous access is maintained with compatible fluid according to local policy while the patient is assessed and help is obtained.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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50 free Clinical Judgement and Prioritisation MCQs from International Nursing Practice, each with the correct answer and an explanation. Unlimited attempts, no account needed.
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