A client received a blood transfusion 4 hours ago and now reports feeling lightheaded and dizzy. The nurse notes a drop in blood pressure and an increase in heart rate. What intervention should the nurse implement first?
Administer a bolus of normal saline.
Elevate the client's feet and lower the head.
Check the client's hemoglobin and hematocrit levels.
Notify the healthcare provider for further evaluation.
The Correct Answer is B
A) Incorrect: Administering a bolus of normal saline may help increase intravascular volume, but it is not the first intervention to be implemented. The nurse should first identify the cause of the client's symptoms and take appropriate actions.
B) Correct: The client's symptoms of feeling lightheaded and dizzy, along with a drop in blood pressure and an increase in heart rate, suggest orthostatic hypotension. The nurse's first intervention should be to elevate the client's feet and lower the head to improve blood flow to the brain.
C) Incorrect: Checking the client's hemoglobin and hematocrit levels is essential but may not be the first intervention in this situation. The client's symptoms indicate an immediate need to address the orthostatic hypotension.
D) Incorrect: Notifying the healthcare provider for further evaluation is important, but it may not be the first intervention. The nurse should first take immediate actions to address the client's symptoms of orthostatic hypotension.
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Related Questions
Correct Answer is C
Explanation
A) Incorrect: Slowing down the transfusion rate is not the appropriate action in this scenario. The client is experiencing signs of an allergic reaction, and the nurse must act promptly to address the situation.
B) Incorrect: Elevating the client's feet and lowering the head (Trendelenburg position) is not indicated for an allergic reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.
C) Correct: The nurse should immediately discontinue the transfusion and initiate the infusion of normal saline to maintain the client's intravascular volume. Discontinuing the blood transfusion helps prevent further exposure to the allergen (if an allergic reaction is confirmed) and addresses fluid volume needs.
D) Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic reaction, it is not the immediate action. The nurse should first discontinue the transfusion and infuse normal saline as stated in option C.
Correct Answer is A
Explanation
A) Correct: Fresh Frozen Plasma (FFP) contains various clotting factors and is used to treat clotting factor deficiencies such as those found in coagulopathies or liver disease.
B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction, not clotting factor deficiencies.
C) Incorrect: Cryoprecipitate is derived from FFP and contains concentrated fibrinogen and other clotting factors. It is used for specific clotting factor deficiencies but is not the primary treatment for clotting factor deficiencies in general.
D) Incorrect: Packed Red Blood Cells (PRBCs) are used to treat anemia and improve oxygenation but do not address clotting factor deficiencies.
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