A nurse is caring for a client who has undergone major surgery and has a hemoglobin level of 8 g/dL. The client is experiencing symptoms of hypoxia, including tachycardia and shortness of breath. The nurse suspects the need for a blood transfusion. What action should the nurse take first?
Notify the healthcare provider immediately to obtain a blood transfusion order.
Administer supplemental oxygen to the client to improve oxygenation.
Initiate intravenous access with a large-bore catheter for possible transfusion.
Encourage the client to ambulate to improve blood circulation.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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
Correct Answer is D
Explanation
A. Notifying the healthcare provider is important, but the immediate priority is to stop the transfusion to prevent further exposure to the potential offending blood product.
B. Administering antipyretics addresses fever but does not stop the transfusion, so it does not prevent worsening of a potentially serious reaction.
C. Preparing a diuretic may be appropriate for fluid overload, but the symptoms described (fever, chills, shortness of breath) suggest a transfusion reaction, not just fluid overload. Immediate action is needed to prevent harm.
D. Discontinuing the blood transfusion immediately is the priority action because it prevents additional exposure to the blood product causing the reaction and is the first step in transfusion reaction protocols.
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