A nurse is caring for a client who has undergone major surgery and has a hemoglobin level of 8 g/dL. The client is experiencing symptoms of hypoxia, including tachycardia and shortness of breath. The nurse suspects the need for a blood transfusion. What action should the nurse take first?

Notify the healthcare provider immediately to obtain a blood transfusion order.

Administer supplemental oxygen to the client to improve oxygenation.

Initiate intravenous access with a large-bore catheter for possible transfusion.

Encourage the client to ambulate to improve blood circulation.

Answer and Explanation

The Correct Answer is A

A: Notify the healthcare provider immediately to obtain a blood transfusion order – This is the priority action because the client’s hemoglobin level of 8 g/dL, along with symptoms of hypoxia, indicates a need for urgent medical intervention. Obtaining an order for a transfusion is crucial for addressing the underlying issue of low hemoglobin and associated hypoxia.
B: Administer supplemental oxygen to the client to improve oxygenation – While this action is important, it is not the first step. The low hemoglobin indicates a need for a transfusion, and notifying the provider can lead to quicker treatment.
C: Initiating IV access with a large-bore catheter is an important step in preparation for a possible blood transfusion, but it is not the first action. The client's current symptoms must be managed promptly.
D: Ambulation may be contraindicated post-major surgery, especially when the client is symptomatic. It could exacerbate the client's condition and is not the immediate priority in this scenario.

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Correct Answer is C

Explanation

A) Incorrect: Transfusing whole blood increases the risk of adverse reactions and is not commonly used in modern transfusion practices. Whole blood is usually separated into its individual components for transfusion.

B) Incorrect: Fresh frozen plasma (FFP) contains various clotting factors and is used primarily to treat bleeding disorders and coagulopathies, not to prevent transfusion reactions.

C) Correct: Packed red blood cells (PRBCs) contain primarily red blood cells without significant amounts of plasma, white blood cells, or platelets. For clients with a history of transfusion reactions, PRBCs are the most suitable blood component to minimize the risk of future reactions.

D) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction but do not provide the main benefit of minimizing the risk of future transfusion reactions as PRBCs do.

A. Pre-medicate the client with antihistamines before the transfusion. B. Administer the blood transfusion rapidly to minimize exposure. C. Ensure that the blood product is warmed before administration. D. Monitor the client's vital signs frequently during the transfusion.

Correct Answer is A

Explanation

A) Correct: Pre-medicating the client with antihistamines before the transfusion can help prevent or minimize allergic transfusion reactions in clients with a history of severe allergies. Antihistamines block histamine release, reducing the risk of allergic symptoms.

B) Incorrect: Administering the blood transfusion rapidly is not a preventive measure for allergic transfusion reactions. In fact, rapid administration may increase the risk of adverse reactions.

C) Incorrect: Warming the blood product before administration is important to prevent hypothermia but is not directly related to preventing allergic transfusion reactions.

D) Incorrect: Monitoring the client's vital signs during the transfusion is a standard practice, but it is not the primary intervention for preventing allergic transfusion reactions. Pre-medication with antihistamines is a more targeted approach.

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A nurse is caring for a client who has undergone major surgery and has a hemoglobin level of 8 g/dL. The client is experiencing symptoms of hypoxia, including tachycardia and shortness of breath. The nurse suspects the need for a blood transfusion. What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of transfusion reactions requires a blood transfusion. Which blood component should the nurse ensure is transfused to minimize the risk of a future reaction?

Correct Answer is C

Explanation

A client has a history of severe allergic reactions and is scheduled to receive a blood transfusion. What intervention should the nurse implement to prevent an allergic transfusion reaction in this client?

Correct Answer is A

Explanation

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