During a blood transfusion, the patient begins to have chills and back pain. What is the nurse™s priority action?

Correct Answer: D

Rationale: The nurse's priority action would be to discontinue the infusion immediately and notify the prescriber. The patient developing chills and back pain during a blood transfusion may be signs of a transfusion reaction, possibly indicating an incompatibility or adverse reaction to the blood product. It is crucial to stop the transfusion to prevent further complications and to notify the prescriber immediately so that appropriate interventions can be initiated promptly. Observing for other symptoms and slowing the infusion rate are secondary actions compared to discontinuing the infusion and informing the prescriber in this situation. Telling the patient that these symptoms are a normal reaction to the blood product is incorrect as the symptoms could indicate a serious issue that needs to be addressed promptly.

Correct Answer: D

Rationale: The most concerning adverse effect for an older adult patient taking a vasodilator for hypertension is hypotension, which refers to abnormally low blood pressure levels. Older adults are more susceptible to experiencing drops in blood pressure due to age-related changes in their cardiovascular system. Vasodilators work by dilating blood vessels, which can further lower blood pressure. Excessive hypotension can lead to symptoms such as dizziness, lightheadedness, weakness, and falls, which can be particularly dangerous for older adults who are at a higher risk of injury. Close monitoring of blood pressure and gradual dosage titration are essential in older adult patients to minimize the risk of hypotension.

Correct Answer: C

Rationale: Milrinone (Primacor) is a phosphodiesterase inhibitor that acts by increasing the levels of cyclic adenosine monophosphate (cAMP) in cardiac muscle cells. This leads to an increased force of cardiac contractions, which is known as a positive inotropic effect. This effect results in the heart muscle contracting more forcefully, leading to an increased cardiac output. The other options (A. Increased heart rate, B. Increased blood vessel dilation, D. Increased conduction of electrical impulses across the heart) do not directly relate to the inotropic effect of milrinone.

Correct Answer: A

Rationale: The nurse will know that it is important to teach the patient to take extra precautions when standing up because of the potential risk of orthostatic hypotension and falls while taking a diuretic for hypertension. Orthostatic hypotension is a common side effect of diuretics, which can lead to dizziness or lightheadedness when changing positions, particularly when standing up quickly. This can increase the risk of falls and injury, especially in elderly patients like this 79-year-old individual. Therefore, the teaching point about taking extra precautions while standing up is crucial for the safety and well-being of the patient.

Correct Answer: A

Rationale: ACE inhibitors are known to cause a decrease in blood pressure as part of their mechanism of action. Monitoring the patient's blood pressure regularly while on ACE inhibitors is crucial to identify any significant drops that may lead to hypotension. This proactive monitoring allows healthcare providers to adjust the dosage of the medication or provide necessary interventions to prevent adverse effects such as dizziness, syncope, or compromised tissue perfusion. Monitoring ins and outs with patients using ACE inhibitors primarily focuses on assessing for potential decreased blood pressure as a key safety measure during treatment.