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Question

Difficulty: EasyEstablishing Priorities

While administering morning medications, a nurse is interrupted by several simultaneous client situations. Which situation requires the nurse's immediate attention?

  1. A client receiving a packed red blood cell transfusion who reports sudden chills and lower back pain.Answer
  2. B
    A client's intravenous infusion pump repeatedly alarming for an occlusion on a continuous normal saline line.
  3. C
    A client with chronic obstructive pulmonary disease (COPD) resting in bed with an oxygen saturation of 91%.
  4. D
    A client repeatedly pressing the call light for assistance to walk to the bathroom.

Answer

The client receiving a packed red blood cell transfusion who reports sudden chills and lower back pain.
The correct answer identifies a client experiencing an acute hemolytic transfusion reaction, indicated by sudden chills and back pain. This is a life-threatening emergency that requires the nurse to stop the transfusion immediately to prevent renal failure or shock.

Step-by-Step Solution

1
Evaluate the clinical significance of sudden chills and back pain during a blood transfusion.
Identified as classic signs of an acute hemolytic transfusion reaction.
Recognizing life-threatening complications is the first step in clinical triage.
2
Compare the severity of the transfusion reaction to the other client scenarios.
The transfusion reaction is an acute, unstable emergency, whereas the other situations represent chronic expected findings, equipment issues, or routine care needs.
Prioritization requires identifying the client with the most unstable and immediately life-threatening condition.

Key Concept

Prioritizing Acute vs. Chronic and Unstable vs. Stable Clients
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Topics

Establishing Priorities

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