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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) Incorrect: Administering epinephrine is not the appropriate intervention for an allergic transfusion reaction characterized by urticaria and itching. Epinephrine is used to treat anaphylactic reactions.

B) Incorrect: Stopping the transfusion and disconnecting the IV tubing is appropriate in the event of an allergic transfusion reaction, but it should not be the first action. The nurse should first slow down or stop the transfusion if mild symptoms are present and notify the healthcare provider for further instructions.

C) Correct: Slowing down the transfusion rate may be appropriate for mild allergic reactions to reduce symptoms. However, if the reaction worsens, the nurse should stop the transfusion immediately.

D) Incorrect: Obtaining a blood sample for repeat crossmatching is not indicated in an allergic transfusion reaction. Allergic reactions are related to hypersensitivity to plasma proteins and do not involve compatibility issues between red blood cells and plasma.

Questions

A. Confirm the client's identity and blood type with the client's family member. B. Obtain informed consent from the client and ensure the client has a signed consent form. C. Warm the blood unit to body temperature in a microwave oven to prevent hypothermia. D. Administer a rapid bolus of normal saline to prime the client's veins.

Correct Answer is B

Explanation

A) Incorrect: Confirming the client's identity and blood type with the client's family member is not a reliable method for ensuring patient safety during a blood transfusion. The nurse should directly verify the client's identity and blood type with two unique identifiers, such as asking the client to state their full name and date of birth and comparing it to their identification band.

B) Correct: Obtaining informed consent from the client is a crucial step before initiating a blood transfusion. The nurse must ensure the client understands the risks and benefits of the transfusion and has willingly provided consent. A signed consent form is the formal documentation of this process.

C) Incorrect: Warming blood in a microwave oven is not an appropriate method for preventing hypothermia and can lead to hemolysis of the blood components. Blood should be warmed using an approved blood warmer designed for this purpose.

D) Incorrect: Administering a rapid bolus of normal saline is unnecessary and could lead to fluid overload in the client. The nurse should administer normal saline or another appropriate IV fluid at the prescribed rate if the client requires hydration before or after the transfusion, but not as a priming method.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who develops urticaria (hives) and itching during a blood transfusion. The nurse suspects an allergic transfusion reaction. What is the appropriate nursing action?

Correct Answer is C

Explanation

A nurse is preparing to administer a blood transfusion to a client. Which action should the nurse take before initiating the transfusion?

Correct Answer is B

Explanation

A client with a history of transfusion reactions requires a blood transfusion. Which blood component should the nurse ensure is transfused to minimize the risk of a future reaction?

A nurse is monitoring a client who just received a blood transfusion. The client suddenly develops dyspnea, tachycardia, and chest pain. What is the nurse's priority action?

A client develops respiratory distress and chest pain during a blood transfusion. The nurse suspects a transfusion-related acute lung injury (TRALI). What is the nurse's priority intervention?

A nurse is caring for a client who experienced a mild allergic reaction during a blood transfusion. Which action should the nurse take to prevent future allergic reactions in this client?

A client is scheduled to receive a blood transfusion, but the nurse discovers that the blood product appears discolored or contains clots. What should the nurse do next?

A client expresses anxiety and fear about receiving a blood transfusion. What action should the nurse take to address the client's concerns?

A nurse is preparing to crossmatch blood for a client with blood type O-positive(O+). Which blood type can safely receive blood from this client?

A nurse is preparing to crossmatch blood for a client who requires a blood transfusion. Which blood component is involved in the crossmatching process?