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.
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Related Questions
Correct Answer is C
Explanation
A) Incorrect: Administering antipyretics to reduce fever is not the appropriate intervention for an acute hemolytic transfusion reaction. This type of reaction involves the destruction of red blood cells, not an elevation in body temperature.
B) Incorrect: Preparing to administer a diuretic is not the appropriate intervention for an acute hemolytic transfusion reaction. Fluid overload is not a typical feature of this type of reaction.
C) Correct: Monitoring the client's vital signs frequently is a crucial intervention for an acute hemolytic transfusion reaction. This type of reaction can cause rapid onset of severe symptoms, including fever, chills, hypotension, tachycardia, and potential shock.
D) Incorrect: Administering epinephrine is not the appropriate intervention for an acute hemolytic transfusion reaction. Epinephrine is used to treat anaphylactic reactions, not hemolytic reactions.
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.
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