A patient receiving blood begins complaining of severe chest pain and a feeling of warmth. What should the nurse do first?

Correct Answer: C

Rationale: The correct first action is to discontinue the blood transfusion (Choice C). This is because the patient's symptoms of severe chest pain and warmth suggest a possible transfusion reaction, which can be life-threatening. By stopping the transfusion, the nurse can prevent further harm to the patient. Calling the physician (Choice A) can be done after stopping the transfusion. Administering diuretics (Choice B) without knowing the cause of symptoms can exacerbate the situation. Assessing vital signs and cardiovascular status (Choice D) is important but should come after stopping the transfusion to prioritize patient safety.

Correct Answer: A

Rationale: The correct answer is A: Dehydration. When a patient is dehydrated, their blood volume decreases, leading to a relative increase in the concentration of red blood cells and hematocrit level. In this case, the patient's high hematocrit level of 50% indicates hemoconcentration due to dehydration. Oxygen saturation being normal suggests that the body is compensating for the decreased blood volume by maintaining adequate oxygen delivery. Summary of incorrect choices: B: Chronic renal failure would likely result in anemia due to decreased erythropoietin production. C: Bone marrow suppression would lead to a decrease in red blood cell production, causing anemia. D: Bleeding esophageal varices would result in acute blood loss and a decreased hematocrit level.

Correct Answer: D

Rationale: The correct answer is D. Having the patient lie on the left side for 1 hour after a bone marrow aspiration helps to prevent bleeding by applying pressure to the site. This position helps to promote clotting and reduces the risk of hematoma formation. Elevating the head of the bed (choice A) is not necessary for this procedure. Applying a sterile 2-inch gauze dressing (choice B) is important but does not address the immediate post-procedure care. Using a half-inch sterile gauze to pack the wound (choice C) is not recommended as it may disrupt the clotting process.

Correct Answer: D

Rationale: The correct answer is D. In chronic obstructive pulmonary disease (COPD), the lungs are unable to efficiently exchange oxygen and carbon dioxide, leading to tissue hypoxia. The body compensates for this by producing more red blood cells (polycythemia) to increase oxygen-carrying capacity. This helps deliver more oxygen to tissues. Choice A is incorrect because medications for bronchodilation do not directly cause polycythemia. Choice B is incorrect because overactive bone marrow is not the primary reason for polycythemia in COPD. Choice C is incorrect because polycythemia in COPD is not a response to combat anemia but rather to address tissue hypoxia.

Correct Answer: C

Rationale: The correct answer is C because a prothrombin time (PT) of 28 seconds indicates a prolonged clotting time, putting the client at risk for bleeding. This requires immediate assessment and intervention to prevent complications. Choice A (INR of 2.8) is within the therapeutic range for clients on anticoagulant therapy, so it does not require immediate attention. Choice B (platelet count of 128000/mm³) is low but not critically low enough to warrant immediate action unless there are signs of active bleeding. Choice D (red blood cell count of 5.1 million/L) is within normal limits and does not indicate an urgent issue.