A nurse is caring for a client with hypovolemic shock due to hemorrhage. Which intervention should the nurse prioritize during the initial resuscitation phase?

Administering intravenous (IV) fluids rapidly.

Administering supplemental oxygen.

Monitoring the client's blood glucose levels.

Performing neurological assessments.

Answer and Explanation

The Correct Answer is A

A) Correct. The priority during the initial resuscitation phase of hypovolemic shock is to replace lost intravascular volume promptly. Administering IV fluids rapidly is crucial to improve tissue perfusion and blood pressure.

B) Incorrect. While administering supplemental oxygen is important for tissue oxygenation, it is not the primary intervention during the initial resuscitation phase.

C) Incorrect. Monitoring blood glucose levels is important for overall assessment but is not the priority during the initial resuscitation phase of hypovolemic shock.

D) Incorrect. Neurological assessments are essential but may not be the immediate priority during the initial resuscitation phase of hypovolemic shock.

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Correct Answer is A

Explanation

A) Correct. Before administering a blood transfusion, obtaining informed consent from the client is essential to ensure the client understands the procedure, its potential risks, and provides their voluntary agreement for the transfusion.

B) Incorrect. While pain assessment is important, it is not the most crucial action before starting a blood transfusion.

C) Incorrect. Prophylactic antibiotics are not typically administered before a blood transfusion unless specifically indicated for the client's condition.

D) Incorrect. While taking vital signs is important, obtaining consent is more critical before starting a blood transfusion.

A. "You can resume normal activities immediately." B. "Monitor for signs of infection at the transfusion site." C. "Avoid consuming citrus fruits and juices." D. "Expect dark-colored stools after the transfusion."

Correct Answer is B

Explanation

A) Incorrect. While resuming normal activities is important, the client should also be cautious and monitor for any complications after a blood transfusion.

B) Correct. Monitoring for signs of infection at the transfusion site is crucial to identify any potential complications such as infection or infiltration.

C) Incorrect. Consuming citrus fruits and juices is not contraindicated after a blood transfusion and does not directly impact post-transfusion care.

D) Incorrect. Dark-colored stools are not an expected outcome after a blood transfusion. It is important for the client to be aware of any unusual changes in stool color or other potential side effects.

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A nurse is caring for a client with hypovolemic shock due to hemorrhage. Which intervention should the nurse prioritize during the initial resuscitation phase?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a blood transfusion to a client with hemorrhagic shock. Which action is essential before starting the transfusion?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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