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","D","E"]
Explanation
Choice A rationale:
A+ blood can be safely transfused to a client with blood type O-.
The rationale is that the recipient, in this case, does not have antibodies against the A antigen, which is present on A+ blood.
Therefore, there is no antigen-antibody reaction.
Choice B rationale:
B- blood can be safely transfused to a client with blood type O-.
The rationale is similar to choice A, as the recipient does not have antibodies against the B antigen, which is present on B- blood.
Choice C rationale:
AB+ blood contains both A and B antigens and RhD antigen, which can potentially react with antibodies present in a client with blood type O-.
Therefore, it is not safe to transfuse AB+ blood to a client with blood type O-.
Choice D rationale:
O+ blood can be safely transfused to a client with blood type O-.
The rationale is that O+ blood does not have A or B antigens, which could react with antibodies present in the recipient.
Choice E rationale:
O- blood is compatible with blood type O- because it does not contain A, B, or RhD antigens, which could be targeted by antibodies in the recipient.
Correct Answer is C
Explanation
Choice A rationale:
Transfusion-associated graft-versus-host disease (TA-GVHD) typically presents with symptoms of fever, rash, diarrhea, and pancytopenia 1 to 6 weeks after transfusion.
It is a delayed reaction, but it does not cause epistaxis, hematuria, and menorrhagia, which are bleeding symptoms.
Therefore, it is an unlikely choice for this scenario.
Choice B rationale:
Transfusion-related immunomodulation (TRIM) is a theory that blood transfusions may affect the immune system, but it does not typically present with the specific bleeding symptoms described in the scenario.
TRIM is more concerned with the immunosuppressive effects of transfusions.
Choice C rationale:
Post-transfusion purpura is a rare condition that occurs 5 to 12 days after a transfusion.
It is characterized by sudden severe thrombocytopenia (low platelet count) and bleeding symptoms, which can include epistaxis (nosebleeds), hematuria (blood in the urine), and menorrhagia (excessive menstrual bleeding)
This aligns with the symptoms described in the scenario, making it the most likely cause.
Choice D rationale:
Viral infections can be a complication of blood transfusions, but they do not typically present with these specific bleeding symptoms within 7 days after the transfusion.
Viral infections may cause a broader range of symptoms and have a longer incubation period.
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