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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct: Fresh Frozen Plasma (FFP) contains various clotting factors and is used to manage clotting factor deficiencies, including those related to liver disease.
B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction but do not primarily address clotting factor deficiencies caused by liver disease.
C) Incorrect: Cryoprecipitate is derived from FFP and contains concentrated fibrinogen and other clotting factors. It may be used in some cases of liver disease, but FFP is the more common choice for managing these conditions.
D) Incorrect: Packed Red Blood Cells (PRBCs) are used to improve oxygenation in anemic clients and are not the primary treatment for clotting factor deficiencies related to liver disease.
Questions
Correct Answer is D
Explanation
A) Incorrect: Fresh Frozen Plasma (FFP) contains clotting factors and is not the primary treatment for hypoalbuminemia.
B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction, not hypoalbuminemia.
C) Incorrect: Packed Red Blood Cells (PRBCs) are primarily used to improve oxygenation in anemic clients and do not address hypoalbuminemia.
D) Correct: Albumin is the blood product of choice for addressing severe hypoalbuminemia. It is a protein that helps maintain oncotic pressure and regulates fluid balance within the blood vessels.
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