This question-specific review guide is tied to the answer reasoning for a PracticeTestVault item. Use it after you answer the question so the review stays focused on what the prompt actually tested.
What this question is testing
Objective: Clinical Judgment
Prompt focus: A nurse is caring for a client receiving a unit of packed red blood cells. Fifteen minutes into the transfusion, the client reports chills, low back pain, and a feeling of apprehension. Which action should the nurse take first?
Why the correct answer works
Stop the transfusion and keep the IV line open with normal saline
Stopping the transfusion and maintaining IV access with saline is the first step in managing a suspected hemolytic reaction.
Why the tempting wrong answer fails
Giving an antipyretic without stopping the transfusion delays treatment of a potentially fatal reaction.
Plain-language takeaway
Chills, low back pain, and apprehension early in a transfusion suggest an acute hemolytic transfusion reaction, a medical emergency. The nurse must immediately stop the transfusion, disconnect the blood tubing, and maintain venous access with normal saline using new tubing. Continuing or…
Simple analogy
Think of clinical judgment like following a short checklist: identify the clue, confirm the rule, and then make the move that fits this exact scenario.
How to review it before a retake
- Underline the command word and name what the question is asking before rereading the choices.
- Compare the correct answer against the closest distractor and write the exact detail that separates them.
- Retest this objective with a fresh question without looking at the rationale first.