A nurse is reviewing the laboratory results of a client with suspected hemorrhage. Which finding should the nurse expect to observe in a client experiencing acute blood loss?

Decreased platelet count.

Elevated hemoglobin levels.

Increased white blood cell count.

Elevated liver enzymes.

Answer and Explanation

The Correct Answer is B

A) Incorrect. Acute blood loss does not typically lead to a decreased platelet count. Platelet levels may remain within the normal range or slightly decrease due to hemodilution.

B) Correct. In acute blood loss, the concentration of red blood cells decreases, leading to hemoconcentration and elevated hemoglobin levels. This is the body's initial response to conserve oxygen-carrying capacity.

C) Incorrect. An increased white blood cell count is not a direct result of acute blood loss and may indicate other inflammatory or infectious processes.

D) Incorrect. Elevated liver enzymes are not a typical finding in acute blood loss. They are more indicative of liver injury or dysfunction.

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Correct Answer is C

Explanation

A) Incorrect. Administering oxygen is essential for a client experiencing difficulty breathing, but the nurse's immediate action should be to stop the blood transfusion and notify the healthcare provider.

B) Incorrect. While assessing the client's vital signs is important, the priority action is to stop the blood transfusion and seek immediate medical assistance.

C) Correct. Sudden difficulty breathing and chest pain after a blood transfusion may indicate an allergic reaction or transfusion-related acute lung injury (TRALI). The nurse should stop the transfusion immediately and inform the healthcare provider.

D) Incorrect. Elevating the head of the client's bed may be helpful in managing respiratory distress, but it is not the priority when there is a potential adverse reaction to the blood transfusion.

A. Obtaining a written consent from the client. B. Assessing the client's level of pain. C. Administering prophylactic antibiotics. D. Taking the client's vital signs.

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.

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A nurse is reviewing the laboratory results of a client with suspected hemorrhage. Which finding should the nurse expect to observe in a client experiencing acute blood loss?

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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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