A client expresses anxiety and fear about receiving a blood transfusion. What action should the nurse take to address the client's concerns?

Explain the blood transfusion procedure in detail to the client.

Offer the client a warm blanket to help them relax during the transfusion.

Ask the healthcare provider to order a sedative for the client before the transfusion.

Provide the client with information about the benefits and risks of the transfusion.

Answer and Explanation

The Correct Answer is D

A) Incorrect: While explaining the blood transfusion procedure is essential, doing so in excessive detail may increase the client's anxiety. The nurse should provide information in a clear and concise manner, addressing the client's specific concerns.

B) Incorrect: Offering a warm blanket is a comfort measure but may not be sufficient to address the client's anxiety and fear about the transfusion. The nurse should engage in therapeutic communication and provide emotional support.

C) Incorrect: Requesting a sedative for the client may not be the best course of action unless specifically prescribed by the healthcare provider. It is essential to explore other interventions to address the client's anxiety before resorting to medication.

D) Correct: Providing the client with information about the benefits and risks of the transfusion can help alleviate their anxiety and fear. The nurse should engage in patient education, discuss the purpose of the transfusion, potential benefits, and possible risks involved. This empowers the client with knowledge and helps them make informed decisions.

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Correct Answer is C

Explanation

A) Incorrect: Mild itching on the client's forearms is a common and expected side effect of a blood transfusion and may not require immediate reporting to the healthcare provider.

B) Incorrect: Mild lower back pain that subsides is not a significant finding and may not require immediate reporting to the healthcare provider.

C) Correct: An increase in blood pressure by 10 mmHg from the client's baseline may indicate a potential transfusion reaction or fluid overload. The nurse should report this finding to the healthcare provider for further evaluation.

D) Incorrect: An increase in hemoglobin level by 2 g/dL after the transfusion is a positive outcome, indicating a successful transfusion. There is no need to report this finding to the healthcare provider.

A. Client reports mild headache. B. Client has slightly elevated temperature. C. Client's skin appears pale and cool to touch. D. Client experiences generalized muscle weakness.

Correct Answer is B

Explanation

A) Incorrect: A mild headache is a common and expected side effect of a blood transfusion and may not require immediate reporting to the healthcare provider.

B) Correct: A slightly elevated temperature in a client who received a blood transfusion 2 hours ago could indicate a delayed transfusion reaction. The nurse should report this finding to the healthcare provider for further evaluation.

C) Incorrect: Pale and cool skin may be an expected finding in a client who received a blood transfusion, especially if they experienced a rapid transfusion or had a reaction. However, it is not the priority finding to report.

D) Incorrect: Generalized muscle weakness may occur for various reasons and may not be directly related to a delayed transfusion reaction. The nurse should prioritize reporting the slightly elevated temperature.

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A client expresses anxiety and fear about receiving a blood transfusion. What action should the nurse take to address the client's concerns?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing post-transfusion care to a client who just received a blood transfusion. Which assessment finding should the nurse report to the healthcare provider immediately?

Correct Answer is C

Explanation

A client received a blood transfusion 2 hours ago. The nurse is assessing for signs of a delayed transfusion reaction. Which assessment finding should the nurse report to the healthcare provider?

Correct Answer is B

Explanation

A client develops respiratory distress and chest pain during a blood transfusion. The nurse suspects a transfusion-related acute lung injury (TRALI). What is the nurse's priority intervention?

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