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: Iron-deficiency anemia is not a contraindication for a blood transfusion. In fact, it is one of the common indications for transfusion in clients with severe anemia.

B) Incorrect: Chronic kidney disease is not a contraindication for a blood transfusion. Transfusions may be necessary for clients with chronic kidney disease who develop anemia due to decreased erythropoietin production.

C) Correct: Hemolytic anemia is a contraindication for a blood transfusion. This condition involves the destruction of red blood cells, and a transfusion with incompatible blood can worsen the hemolysis and lead to a severe transfusion reaction.

D) Incorrect: Hypertension is not a contraindication for a blood transfusion. While the nurse should monitor blood pressure during the transfusion, hypertension alone does not preclude the need for a transfusion in a client with other indications for blood products.

A. A-negative (A-), B-negative (B-), AB-positive (AB+), and O-positive (O+). B. A-positive (A+), AB-negative (AB-), O-positive (O+), and B-negative (B-). C. AB-negative (AB-), O-positive (O+), AB-positive (AB+), and B-positive (B+). D. O-negative (O-), B-positive (B+), and O-positive (O+). E. None F. None

Correct Answer is D

Explanation

A. A-negative (A-) and AB-positive (AB+) are incompatible with B-positive (B+), as individuals with B+ blood can only receive blood from B or O types.
B. A-positive (A+) and AB-negative (AB-) are incompatible for the same reason.
C. AB-negative (AB-) and AB-positive (AB+) are not suitable donors for B-positive (B+) recipients.
D. O-negative (O-), B-positive (B+), and O-positive (O+) are all compatible with B-positive (B+), making this the correct choice.

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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 assessing a client's history before a blood transfusion. Which condition should the nurse identify as a contraindication for transfusion?

Correct Answer is C

Explanation

A client with blood type B-positive (B+) requires a blood transfusion. Which blood types are compatible with this client for a crossmatch?

Correct Answer is D

Explanation

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