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A Client Is Receiving a Blood Transfusion

Question 114

Multiple Choice

A client is receiving a blood transfusion.  Fifteen minutes after the transfusion starts, the nurse notes a drop in blood pressure from 110/70 to 84/50 mm Hg.  The client reports "feeling a little cold."  Based on this assessment, in what order should the nurse complete the following actions?  All options must be used.


A) Administer prescribed vasopressor
B) Collect urine specimen
C) Document the occurrence
D) Stop the blood transfusion
E) Using new tubing, infuse normal saline into the vein

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