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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Autologous transfusion involves collecting and storing the patient's blood before a planned surgery or procedure, eliminating the risk of incompatibility, infection, and immunologic reactions associated with allogeneic (donor) blood transfusions.
This option aligns with the patient's religious beliefs and offers a safe alternative.
Choice B rationale:
Erythropoietin therapy stimulates red blood cell production but does not eliminate the need for transfusion entirely.
It may not align with the patient's refusal of blood products due to religious beliefs.
Choice C rationale:
Iron therapy can increase hemoglobin levels but may not completely eliminate the need for transfusion.
It also may not be a suitable alternative for the patient's specific condition.
Choice D rationale:
Hemostatic agents are not a substitute for blood transfusion.
They are used to control bleeding but do not address anemia or increase hemoglobin levels.
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.
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