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 ["A","B","C","E"]
Explanation
Choice A rationale:
Ensuring that blood products meet quality and safety standards is a fundamental aspect of blood transfusion safety.
Blood products must be properly screened and tested for infectious diseases and compatibility to reduce the risk of adverse reactions in the recipient.
Choice B rationale:
Using the right blood product for the right patient at the right time is a critical safety measure.
Administering the wrong blood type or product can lead to severe and life-threatening reactions, such as hemolytic transfusion reactions.
Choice C rationale:
Applying a barcode system or electronic verification system for patient and product identification is essential for ensuring that the correct blood product is matched to the right patient.
This technology helps prevent administration errors.
Choice D rationale:
Administering blood products using reusable equipment is not recommended due to the risk of cross-contamination and infection transmission.
Single-use, disposable equipment is the standard for blood transfusion to enhance safety.
Choice E rationale:
Disposing of used blood products and materials according to hospital policy is crucial to prevent potential contamination and reduce the risk of infection transmission.
Proper disposal procedures are a part of overall transfusion safety protocols.
Choice D is not a recommended safety measure as using reusable equipment for blood transfusions can increase the risk of contamination and transmission of infections.
Therefore, it should not be included as part of blood transfusion safety measures.
Correct Answer is C
Explanation
Acute hemolytic reaction.
Choice A rationale:
A febrile nonhemolytic reaction typically presents with fever, chills, and rigors but is not associated with back pain, chest pain, dyspnea, or jaundice.
It is often caused by antibodies to leukocytes or platelets in the donor's blood.
This reaction is usually mild and self-limiting.
Choice B rationale:
Allergic reactions typically present with symptoms like urticaria, pruritus, flushing, and can include mild to moderate fever, but they do not cause back pain, chest pain, dyspnea, or jaundice.
These reactions are usually associated with sensitivity to plasma proteins or allergens in the blood product.
Choice C rationale:
Acute hemolytic reactions involve the rapid destruction of red blood cells, leading to the release of hemoglobin into the bloodstream.
This can cause fever, chills, back pain, chest pain, dyspnea, and jaundice, making it the most likely reaction in this case.
It is usually due to ABO incompatibility between the donor and recipient blood.
Choice D rationale:
Transfusion-associated circulatory overload (TACO) typically presents with symptoms related to volume overload, such as pulmonary edema, hypertension, and tachycardia.
It does not typically manifest with fever, chills, back pain, chest pain, dyspnea, or jaundice.
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