A client has completed a blood transfusion, and the nurse is responsible for post-transfusion care.
What action should the nurse take immediately after the transfusion?
"I'll obtain post-transfusion laboratory tests.”
"I'll return any unused blood product to the blood bank.”
"I'll remove the IV catheter without flushing it.”
"I'll educate the patient about the procedure.”
The Correct Answer is A
Choice A rationale:
The nurse should obtain post-transfusion laboratory tests immediately after the transfusion to assess the patient's response to the blood transfusion.
These tests may include a complete blood count (CBC) to evaluate hemoglobin and hematocrit levels.
Choice B rationale:
Returning any unused blood product to the blood bank is not the immediate action needed after a transfusion.
Post-transfusion laboratory tests and patient assessment take precedence.
Choice C rationale:
Removing the IV catheter without flushing it immediately after the transfusion is not appropriate.
The IV site should be maintained for a period after the transfusion to ensure there are no adverse reactions, and the catheter should be flushed according to the facility's protocol.
Choice D rationale:
Educating the patient about the procedure is important but should be done before the transfusion, not immediately after.
Immediate post-transfusion care involves monitoring the patient and obtaining necessary laboratory tests.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Allergic reaction.
Choice A rationale:
Transfusion-related acute lung injury (TRALI) usually presents with acute respiratory distress, not urticaria, pruritus, and flushing.
It is characterized by the sudden onset of dyspnea, hypoxemia, and pulmonary edema.
Choice B rationale:
Bacterial contamination of blood products can lead to sepsis, but the symptoms described in the question (urticaria, pruritus, and flushing) are not indicative of bacterial contamination.
Symptoms of bacterial contamination would typically include fever, chills, and signs of infection.
Choice C rationale:
Febrile nonhemolytic reactions can cause fever, chills, and rigors, but they are not associated with urticaria, pruritus, or flushing.
Choice D rationale:
An allergic reaction, also known as a hypersensitivity reaction, can manifest with symptoms like urticaria (hives), pruritus (itching), and flushing.
These symptoms are indicative of an allergic response to components in the blood product, such as plasma proteins or allergens.
Correct Answer is C
Explanation
Choice A rationale:
B- blood can be safely transfused to a client with blood type B+ since B+ individuals do not have anti-B antibodies.
However, the reverse is not true.
A client with blood type B+ should not receive B- blood because B- blood has anti-A antibodies that can react with the A antigen present on the recipient's red blood cells.
Choice B rationale:
A- blood can be safely transfused to a client with blood type B+ since B+ individuals do not have anti-A antibodies.
However, the reverse is not true.
A client with blood type B+ should not receive A- blood because A- blood has anti-B antibodies that can react with the B antigen present on the recipient's red blood cells.
Choice C rationale:
O- blood can be safely transfused to a client with blood type B+ because O- blood is universally compatible with all blood types.
O- blood does not contain A, B, or RhD antigens, making it safe for transfusion to recipients with any blood type.
Choice D rationale:
AB- blood can be safely transfused to a client with blood type B+ since B+ individuals do not have anti-A or anti-B antibodies.
However, the reverse is not true.
A client with blood type B+ should not receive AB- blood because AB- blood contains both A and B antigens, which can react with the antibodies present in the recipient's plasma.
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