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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Notifying the healthcare provider is important but should be done after stopping the transfusion to prevent further reaction.
B. Administering acetaminophen does not address the underlying cause of the reaction and should not be the priority.
C. Stopping the transfusion and disconnecting the IV tubing is the first priority to prevent further exposure to the incompatible blood product, which could lead to a life-threatening hemolytic reaction.
D. Infusing normal saline is appropriate to maintain hydration, but it should be done after stopping the transfusion.

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 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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