Fifteen Minutes After Beginning a Transfusion of O Negative Blood

question 1

Multiple Choice

Fifteen minutes after beginning a transfusion of O negative blood to a patient in shock,the nurse assesses a drop in the patient's blood pressure to 60/40 mm Hg,heart rate 135 beats/min,respirations 40 breaths/min,and a temperature of 102° F.The nurse notes the new onset of hematuria in the patient's Foley catheter.What are the priority nursing actions? (Select all that apply.)

• A) Administer acetaminophen.
• B) Document the patient's response.
• C) Increase the rate of transfusion.
• D) Notify the blood bank.
• E) Notify the provider.
• F) Stop the transfusion.

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Definitions:

Merkel Cell

A type of skin cell that functions as a mechanoreceptor, contributing to the sense of touch by detecting pressure and texture.

Lamellated Corpuscle

The lamellated corpuscles, also known as Pacinian corpuscles, are nerve endings in the skin and other tissues that detect pressure and vibration.

Tympanic Membrane

A thin membrane that separates the outer ear from the middle ear, vibrating in response to sound waves and allowing for the perception of sound.

Sound Waves

Vibrations that travel through air or another medium, which can be heard when they reach a person's or animal's ear.