A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take is to administer PRN acetaminophen (Tylenol) to the postoperative patient who is experiencing symptoms of a transfusion reaction. This choice is correct because the symptoms described (chills, fever, headache, and anxiety) are indicative of a febrile non-hemolytic transfusion reaction, which is a common type of transfusion reaction. Acetaminophen can help reduce fever and relieve headache and discomfort associated with the reaction. Option A, giving diphenhydramine, is incorrect because diphenhydramine is typically used to manage allergic reactions, such as urticaria or itching, rather than febrile reactions. Option B, sending a urine specimen to the laboratory, is not the priority in this situation as the patient is experiencing acute symptoms that need immediate attention. Option D, drawing blood for a new type and crossmatch, is not necessary at this point as the priority is managing the patient's symptoms and ensuring their safety. A new type and crossmatch may be needed if a more severe transfusion reaction is suspected, but it is not the immediate action to take in this case. Educationally, it is crucial for nurses to recognize and manage transfusion reactions promptly to prevent further complications. Understanding the signs and symptoms of different types of transfusion reactions, as well as appropriate interventions, is essential in providing safe and effective patient care in the medical-surgical setting.

Correct Answer: A

Rationale: The correct answer is A because patients with aplastic anemia are at risk for infection due to low white blood cell production. Assigning a roommate with viral pneumonia (choice B), cellulitis (choice C), or multiple abdominal drains (choice D) could expose the patient with aplastic anemia to potential infectious agents, which could further compromise their health.

Correct Answer: A

Rationale: The correct answer is A. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/µL unless the patient is actively bleeding. In this case, with a platelet count of 42,000/µL, the count is not critically low, and the patient is not actively bleeding. Therefore, the nurse should consult with the healthcare provider before giving the transfusion. Choices B, C, and D are incorrect because the presence of petechiae, low blood pressure, and oozing from the venipuncture site are common findings in patients with ITP and do not necessarily require immediate consultation before administering a platelet transfusion.

Correct Answer: B

Rationale: Choice B is the correct answer because the scenario describes a 50-year-old with early-stage chronic lymphocytic leukemia who presents with chronic fatigue. Chronic lymphocytic leukemia commonly presents with symptoms like fatigue, weight loss, and enlarged lymph nodes. The other choices are less likely as they do not match the clinical presentation described in the scenario. Choice A describes a 23-year-old with a nontender lump in the axilla, which is more suggestive of a benign condition like a lipoma. Choice C describes a 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement, which is unrelated to the symptoms of chronic lymphocytic leukemia. Choice D repeats the scenario, which is not relevant in selecting the appropriate answer.

Correct Answer: A

Rationale: The correct answer is A. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/µL unless the patient is actively bleeding. In this scenario, the platelet count of 42,000/µL is not significantly low to warrant a platelet transfusion without active bleeding. Consulting with the healthcare provider is essential before giving the transfusion to ensure the appropriateness of the treatment. Choices B, C, and D are not directly related to the need for consulting before a platelet transfusion. Petechiae, low blood pressure, and oozing from the venipuncture site are common findings in patients with ITP and may not necessarily contraindicate a platelet transfusion at this platelet count.