A nurse is providing post-transfusion care to a client who just received a blood transfusion. Which assessment finding should the nurse report to the healthcare provider immediately?

Mild itching on the client's forearms.

Mild lower back pain that subsides.

Blood pressure increase by 10 mmHg from baseline.

Hemoglobin level increase by 2 g/dL after the transfusion.

Answer and Explanation

The Correct Answer is C

A) Incorrect: Mild itching on the client's forearms is a common and expected side effect of a blood transfusion and may not require immediate reporting to the healthcare provider.

B) Incorrect: Mild lower back pain that subsides is not a significant finding and may not require immediate reporting to the healthcare provider.

C) Correct: An increase in blood pressure by 10 mmHg from the client's baseline may indicate a potential transfusion reaction or fluid overload. The nurse should report this finding to the healthcare provider for further evaluation.

D) Incorrect: An increase in hemoglobin level by 2 g/dL after the transfusion is a positive outcome, indicating a successful transfusion. There is no need to report this finding to the healthcare provider.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A) Incorrect: Fresh Frozen Plasma (FFP) contains clotting factors and is used to treat bleeding disorders, but it is not primarily responsible for promoting clot formation and controlling bleeding.

B) Correct: Platelets are responsible for promoting clot formation and controlling bleeding. They play a crucial role in hemostasis and are used to treat thrombocytopenia and platelet dysfunction.

C) Incorrect: Packed Red Blood Cells (PRBCs) primarily carry oxygen and are used to treat anemia and improve oxygenation, but they do not have a direct role in clot formation or controlling bleeding.

D) Incorrect: Albumin is a protein used to expand intravascular volume, especially in cases of hypoalbuminemia, but it does not have a significant role in clot formation or controlling bleeding.

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.

View Question and Answer

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

A nurse is providing post-transfusion care to a client who just received a blood transfusion. Which assessment finding should the nurse report to the healthcare provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a blood component to a client. Which blood component is responsible for promoting clot formation and controlling bleeding?

Correct Answer is B

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 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 with blood type AB-positive (AB+) requires a blood transfusion. Which blood types can safely donate to this client?

A client receiving a blood transfusion suddenly becomes agitated, dyspneic, and reports a sense of impending doom. The nurse assesses the client and notes jugular vein distention and muffled heart sounds. What action should the nurse take next?

A nurse is caring for a client who experiences an acute hemolytic transfusion reaction. What intervention should the nurse anticipate implementing?

A nurse is preparing to initiate a blood transfusion for a client. Which action should the nurse take first to ensure client safety?

A client requires immediate volume replacement due to hypovolemic shock. Which blood product should the nurse anticipate administering to rapidly restore intravascular volume?

A client is receiving a blood transfusion, and the nurse suspects a transfusion-related acute lung injury (TRALI) due to sudden respiratory distress. What action should the nurse take to prevent further complications?

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?