A nurse is caring for a client who experienced a hemorrhage and received a blood transfusion. Which clinical manifestation should the nurse monitor to determine the effectiveness of the transfusion?
Respiratory rate
Blood pressure
Urinary output
Hemoglobin level
The Correct Answer is D
A) Incorrect. While the respiratory rate is an important vital sign to monitor, it does not directly indicate the effectiveness of a blood transfusion.
B) Incorrect. Blood pressure is a critical vital sign, but it is not specific to assessing the effectiveness of a blood transfusion.
C) Incorrect. Urinary output is essential for assessing kidney function and fluid balance, but it does not directly reflect the impact of a blood transfusion.
D) Correct. Monitoring the hemoglobin level is crucial to determine if the blood transfusion has been effective in increasing the client's red blood cell count and improving oxygen-carrying capacity.
Nursing Test Bank
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Related Questions
Correct Answer is B
Explanation
A) Incorrect. Topical antiseptics, such as hydrogen peroxide or alcohol, can help prevent infection but are safe to use on minor cuts when applied correctly.
B) Correct. Applying direct pressure to the bleeding site for at least 10 minutes helps control minor bleeding and allows the blood to clot, reducing the risk of excessive bleeding.
C) Incorrect. Aspirin is an antiplatelet medication and can increase the risk of bleeding. It should not be used to stop bleeding quickly without medical guidance.
D) Incorrect. Elevating the affected limb above the heart level is not typically necessary for minor bleeding episodes and may not be practical for all bleeding sites.
Correct Answer is C
Explanation
A) Incorrect. While a complete blood count (CBC) provides valuable information about the client's red blood cell count and hemoglobin levels, it does not directly confirm the presence of bleeding or assess the clotting function.
B) Incorrect. Magnetic Resonance Imaging (MRI) is a valuable tool for diagnosing various conditions but is not a primary test for confirming the presence of bleeding.
C) Correct. A coagulation panel, which includes prothrombin time (PT) and activated partial thromboplastin time (PTT), helps assess the clotting function and can aid in confirming the presence of bleeding and identifying coagulation disorders.
D) Incorrect. Fecal Occult Blood Test (FOBT) is used to detect hidden blood in stool, which is indicative of lower gastrointestinal bleeding, but it does not confirm internal bleeding in other areas of the body.
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