A client received a blood transfusion 4 hours ago and now reports feeling lightheaded and dizzy. The nurse notes a drop in blood pressure and an increase in heart rate. What intervention should the nurse implement first?
Administer a bolus of normal saline.
Elevate the client's feet and lower the head.
Check the client's hemoglobin and hematocrit levels.
Notify the healthcare provider for further evaluation.
The Correct Answer is B
A) Incorrect: Administering a bolus of normal saline may help increase intravascular volume, but it is not the first intervention to be implemented. The nurse should first identify the cause of the client's symptoms and take appropriate actions.
B) Correct: The client's symptoms of feeling lightheaded and dizzy, along with a drop in blood pressure and an increase in heart rate, suggest orthostatic hypotension. The nurse's first intervention should be to elevate the client's feet and lower the head to improve blood flow to the brain.
C) Incorrect: Checking the client's hemoglobin and hematocrit levels is essential but may not be the first intervention in this situation. The client's symptoms indicate an immediate need to address the orthostatic hypotension.
D) Incorrect: Notifying the healthcare provider for further evaluation is important, but it may not be the first intervention. The nurse should first take immediate actions to address the client's symptoms of orthostatic hypotension.
Questions
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Notify the healthcare provider immediately to obtain a blood transfusion order – This is the priority action because the client’s hemoglobin level of 8 g/dL, along with symptoms of hypoxia, indicates a need for urgent medical intervention. Obtaining an order for a transfusion is crucial for addressing the underlying issue of low hemoglobin and associated hypoxia.
B: Administer supplemental oxygen to the client to improve oxygenation – While this action is important, it is not the first step. The low hemoglobin indicates a need for a transfusion, and notifying the provider can lead to quicker treatment.
C: Initiating IV access with a large-bore catheter is an important step in preparation for a possible blood transfusion, but it is not the first action. The client's current symptoms must be managed promptly.
D: Ambulation may be contraindicated post-major surgery, especially when the client is symptomatic. It could exacerbate the client's condition and is not the immediate priority in this scenario.
Correct Answer is C
Explanation
A) Incorrect: Warming the blood product in a microwave oven is not an appropriate action and could lead to hemolysis of the blood components. Blood should be warmed using an approved blood warmer designed for this purpose.
B) Incorrect: Administering a discolored blood product or one containing clots is unsafe and could cause harm to the client. The nurse should not proceed with the administration and should take appropriate actions.
C) Correct: If the nurse discovers that the blood product is discolored or contains clots, the nurse should discard the blood product appropriately and notify the blood bank immediately. This will ensure that the client receives a safe and suitable blood product for the transfusion.
D) Incorrect: Filtering the blood product through a standard IV filter is not sufficient to remove any clots present in the blood product. Using a blood product that appears abnormal could lead to adverse reactions in the client, so it is essential to obtain a replacement from the blood bank.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.