A nurse is reviewing a client's laboratory results before administering a blood transfusion.
Which of the following results should the nurse report to the provider before proceeding with the transfusion?
Hemoglobin 8 g/dL
Platelets 150,000/mm3
Potassium 5.5 mEq/L
Blood type AB positive
The Correct Answer is C
Potassium 5.5 mEq/L
Rationale: The nurse should report the potassium level of 5.5 mEq/L to the provider before proceeding with
the blood transfusion, as this indicates hyperkalemia, which can cause cardiac arrhythmias or arrest. Blood transfusion can increase potassium levels further, especially if the blood has been stored for a long time or if it is administered rapidly.
Incorrect options:
A) Hemoglobin 8 g/dL - This is a low hemoglobin level, which indicates anemia, but it is not a contraindication for blood transfusion. In fact, blood transfusion may be indicated to treat severe anemia and improve oxygen delivery to the tissues.
B) Platelets 150,000/mm3 - This is a normal platelet count, which indicates adequate clotting function. It is not a reason to withhold or delay blood transfusion.
D) Blood type AB positive - This is the client's blood type, which is compatible with any blood type for transfusion, as AB positive is the universal recipient. It is not a reason to report to the provider or stop the transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client's blood pressure is 180/100 mm Hg and heart rate is 110 beats/min.
Rationale: The nurse should report the client's blood pressure and heart rate to the provider immediately, as these are signs of hypertensive crisis and tachycardia, which can indicate a serious cardiovascular complication, such as myocardial infarction, stroke, or heart failure.
Incorrect options:
A) The client has a history of hypertension and diabetes mellitus. - This is an important information to obtain from the client, as it indicates risk factors for cardiovascular disease. However, this is not an urgent finding that requires immediate reporting to the provider, as it does not reflect the client's current condition or acuity.
B) The client takes aspirin 81 mg daily and metformin 500 mg twice daily. - This is an important information to obtain from the client, as it indicates the medications that the client is taking for their chronic conditions. However, this is not an urgent finding that requires immediate reporting to the provider, as it does not reflect any adverse effects or interactions of these medications.
D) The client's chest pain radiates to the left arm and is relieved by nitroglycerin. - This is an important information to obtain from the client, as it indicates that the client has angina pectoris, which is chest pain caused by reduced blood flow to the heart muscle. However, this is not an urgent finding that requires immediate reporting to the provider, as it shows that the chest pain is stable and responsive to nitroglycerin.
Correct Answer is B
Explanation
Check the tubing for any leaks or kinks.
Rationale: The nurse should check the tubing for any leaks or kinks, as continuous bubbling in the water seal chamber indicates an air leak in the system, which can impair lung re-expansion and drainage. The nurse should locate and seal the leak, and notify the provider if necessary.
Incorrect options:
A) Clamp the chest tube near the insertion site. - This is an incorrect action, as clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition that occurs when air accumulates in the pleural space and compresses the lung and other structures. The nurse should only clamp the chest tube briefly when changing the drainage system or assessing for an air leak.
C) Increase the suction pressure to the drainage system. - This is an incorrect action, as increasing the suction pressure to the drainage system can cause damage to the lung tissue and increase the risk of infection. The nurse should follow
the provider's prescription and the manufacturer's guidelines for setting and adjusting the suction pressure.
D) Document the finding as an expected outcome. - This is an incorrect action, as documenting the finding as an expected outcome implies that continuous bubbling in the water seal chamber is normal, which it is not. The nurse should document
the finding as an abnormal finding and report it to the provider.
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