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.

Answer and Explanation

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.

Questions

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Correct Answer is ["A","B","D"]

Explanation

A) Obtaining the client's informed consent is a critical step before any medical procedure, including blood transfusions. This ensures the client understands the risks and benefits of the transfusion and gives their consent willingly.

B) Confirming the client's blood type and Rh factor with the blood bank is essential to prevent transfusion reactions. Mismatching blood types can lead to severe transfusion reactions and is a crucial step in the transfusion process.

C) Administering pre-medication to prevent transfusion reactions is not a standard practice. However, the nurse should assess the client for any risk factors or history of previous transfusion reactions to take appropriate precautions.

D) Assessing the client's blood pressure and heart rate is an important part of the overall assessment before the blood transfusion.

A. Slow down the transfusion rate. B. Elevate the client's feet and lower the head. C. Discontinue the transfusion and infuse normal saline. D. Administer an antihistamine as prescribed.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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