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?
Mild itching on the client's forearms.
Mild lower back pain that subsides.
Blood pressure increase by 10 mmHg from baseline.
Hemoglobin level increase by 2 g/dL after the transfusion.
The Correct Answer is C
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect: Elevating the head of the bed may help promote lung expansion, but it is not the nurse's priority action when the client is experiencing severe symptoms like dyspnea, tachycardia, and chest pain during a transfusion.
B) Incorrect: Administering diuretics is not the appropriate action for the client's symptoms, which suggest a possible transfusion-related acute lung injury (TRALI) or acute hemolytic transfusion reaction. Diuretics will not address the underlying cause.
C) Correct: The client's symptoms of dyspnea, tachycardia, and chest pain indicate a potential severe transfusion reaction. The nurse's priority action is to stop the transfusion immediately and notify the healthcare provider for further evaluation and intervention.
D) Incorrect: Continuing the transfusion at a slower rate is not appropriate when the client is experiencing severe symptoms. The nurse should first stop the transfusion and then notify the healthcare provider.
Correct Answer is B
Explanation
A) Incorrect: Obtaining a signed informed consent is an essential step before administering a blood transfusion, but it is not the priority action for preventing a potential complication related to blood compatibility. The nurse should first confirm the client's blood type and Rh factor.
B) Correct: The nurse's priority action is to confirm the client's blood type and Rh factor with two unique identifiers to ensure compatibility between the client and the blood product. This step is crucial for preventing transfusion reactions due to ABO and Rh incompatibility.
C) Incorrect: Ensuring that the blood product is properly labeled and has not expired is important for patient safety but is not the priority action before administering a blood transfusion. The nurse should first confirm the client's blood type and Rh factor.
D) Incorrect: Assessing the client's vital signs and baseline laboratory values is essential, but it is not the priority action for preventing a potential complication related to blood compatibility. The nurse should first confirm the client's blood type and Rh factor.
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