A nurse is caring for a client who experiences an acute hemolytic transfusion reaction. What intervention should the nurse anticipate implementing?

Administering antipyretics to reduce fever.

Preparing to administer a diuretic to manage fluid overload.

Monitoring the client's vital signs frequently.

Administering epinephrine to counteract an allergic reaction.

Answer and Explanation

The Correct Answer is C

A) Incorrect: Administering antipyretics to reduce fever is not the appropriate intervention for an acute hemolytic transfusion reaction. This type of reaction involves the destruction of red blood cells, not an elevation in body temperature.

B) Incorrect: Preparing to administer a diuretic is not the appropriate intervention for an acute hemolytic transfusion reaction. Fluid overload is not a typical feature of this type of reaction.

C) Correct: Monitoring the client's vital signs frequently is a crucial intervention for an acute hemolytic transfusion reaction. This type of reaction can cause rapid onset of severe symptoms, including fever, chills, hypotension, tachycardia, and potential shock.

D) Incorrect: Administering epinephrine is not the appropriate intervention for an acute hemolytic transfusion reaction. Epinephrine is used to treat anaphylactic reactions, not hemolytic reactions.

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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. Fresh Frozen Plasma (FFP) B. Platelets C. Cryoprecipitate D. Packed Red Blood Cells (PRBCs)

Correct Answer is A

Explanation

A) Correct: Fresh Frozen Plasma (FFP) contains various clotting factors and is used to manage clotting factor deficiencies, including those related to liver disease.

B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction but do not primarily address clotting factor deficiencies caused by liver disease.

C) Incorrect: Cryoprecipitate is derived from FFP and contains concentrated fibrinogen and other clotting factors. It may be used in some cases of liver disease, but FFP is the more common choice for managing these conditions.

D) Incorrect: Packed Red Blood Cells (PRBCs) are used to improve oxygenation in anemic clients and are not the primary treatment for clotting factor deficiencies related to liver disease.

Questions

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A nurse is caring for a client who experiences an acute hemolytic transfusion reaction. What intervention should the nurse anticipate implementing?

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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 with severe liver disease has a decreased ability to synthesize clotting factors. Which blood product should the nurse anticipate being prescribed to manage the client's condition?

Correct Answer is A

Explanation

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