A client received a blood transfusion 2 hours ago. The nurse is assessing for signs of a delayed transfusion reaction. Which assessment finding should the nurse report to the healthcare provider?
Client reports mild headache.
Client has slightly elevated temperature.
Client's skin appears pale and cool to touch.
Client experiences generalized muscle weakness.
The Correct Answer is B
A) Incorrect: A mild headache is a common and expected side effect of a blood transfusion and may not require immediate reporting to the healthcare provider.
B) Correct: A slightly elevated temperature in a client who received a blood transfusion 2 hours ago could indicate a delayed transfusion reaction. The nurse should report this finding to the healthcare provider for further evaluation.
C) Incorrect: Pale and cool skin may be an expected finding in a client who received a blood transfusion, especially if they experienced a rapid transfusion or had a reaction. However, it is not the priority finding to report.
D) Incorrect: Generalized muscle weakness may occur for various reasons and may not be directly related to a delayed transfusion reaction. The nurse should prioritize reporting the slightly elevated temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct: Red blood cells are the main blood component involved in the crossmatching process. Crossmatching ensures compatibility between the donor's red blood cells and the recipient's plasma, preventing adverse reactions during the transfusion.
B) Incorrect: White blood cells are not part of the crossmatching process. They play a role in the immune response but are not specifically assessed during crossmatching.
C) Incorrect: Platelets are not directly involved in the crossmatching process. Crossmatching primarily focuses on red blood cell compatibility.
D) Incorrect: Plasma is not directly involved in the crossmatching process. The focus is on ensuring compatibility between red blood cells and the recipient's plasma.
Correct Answer is A
Explanation
A) Correct: The client's symptoms of hives, itching, and facial swelling indicate a potential allergic transfusion reaction (urticarial reaction). The nurse's immediate action is to stop the transfusion immediately and notify the healthcare provider for further evaluation and intervention.
B) Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic transfusion reaction, it is not the immediate action. The nurse should first stop the transfusion and notify the healthcare provider.
C) Incorrect: Slowing down the transfusion rate is not appropriate in the presence of an allergic transfusion reaction. The nurse should stop the transfusion immediately.
D) Incorrect: Placing the client in a supine position with legs elevated is not indicated for an allergic transfusion reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.
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