A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. The client's hemoglobin is at 7 g/dL. Which of the following findings should the nurse expect this client to report?
Diarrhea
Fatigue
Hypertension
Bradycardia
The Correct Answer is B
A. Diarrhea is not a typical finding associated with anemia from blood loss; it may occur for other reasons but is not directly related to low hemoglobin levels.
B. Fatigue is a common symptom in clients with anemia, particularly when hemoglobin levels are low, as there is reduced oxygen delivery to tissues, leading to feelings of weakness and tiredness.
C. Hypertension is unlikely to be present in a client with significant blood loss; instead, hypotension may be more expected due to reduced blood volume.
D. Bradycardia is not typically associated with anemia; in fact, tachycardia (increased heart rate) is more common as the body tries to compensate for reduced oxygen-carrying capacity.
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Correct Answer is ["B","C","D","E","F"]
Explanation
A. Hanging a bag of 0.9% normal saline with 5% dextrose (D5%NS) is incorrect; only normal saline (0.9% NS) should be used to prime the blood transfusion line to avoid hemolysis.
B. Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions and ensure the correct blood product is given.
C. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth in the blood product.
D. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition and monitor for any changes during the transfusion.
E. Continuously monitoring the client during the first 15 minutes of the transfusion is vital for detecting any signs of a transfusion reaction promptly.
F. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions as it provides a sufficient lumen to accommodate the blood flow.
G. Inserting a 22-gauge intravenous catheter is acceptable for some transfusions, but an 18-gauge is preferred for larger blood products.
Correct Answer is ["A","C","D","E"]
Explanation
A. Hemoglobin level is a key component of the CBC, reflecting the oxygen-carrying capacity of the blood.
B. Blood glucose level is not part of the CBC; it is typically measured separately in metabolic panels or glucose tests.
C. White blood cell count is included in the CBC and is important for assessing the immune response.
D. Platelet count is also part of the CBC and is essential for evaluating clotting function.
E. Red blood cell count is included in the CBC and is crucial for assessing overall blood health and anemia status.