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 C
Explanation
Choice A rationale:
Oxygen therapy is not a medication used to promote clotting or stop bleeding.
Its primary purpose is to improve oxygen delivery to tissues, especially in cases of hypoxia.
Choice B rationale:
Erythropoietin injections are used to stimulate red blood cell production in conditions like anemia.
While it can indirectly help improve oxygen-carrying capacity, it does not promote clotting or stop bleeding.
Choice C rationale:
Hemostatic agents like vitamin K or tranexamic acid can help promote clotting and stop bleeding.
Vitamin K is essential for the synthesis of clotting factors in the liver, while tranexamic acid is an antifibrinolytic agent that prevents the breakdown of clots.
These medications are often used in bleeding disorders to control hemorrhage.
Choice D rationale:
Iron therapy is used to treat iron-deficiency anemia and increase hemoglobin levels.
It does not have a direct role in promoting clotting or stopping bleeding.
Correct Answer is ["B","E"]
Explanation
Choice A rationale:
Transfusion-associated circulatory overload (TACO) is not caused by antibodies in the donor's plasma.
It is primarily a result of excessive volume administered during a transfusion.
Choice B rationale:
Transfusion-related acute lung injury (TRALI) is indeed a leading cause of transfusion-related mortality.
TRALI is characterized by acute respiratory distress and is caused by antibodies in the donor's plasma that react with leukocytes in the recipient's lungs.
Choice C rationale:
Febrile nonhemolytic reaction is not the most common type of transfusion reaction.
It is relatively common but not the most common.
Other reactions, like allergic reactions or acute hemolytic reactions, can also occur.
Choice D rationale:
Allergic reactions are not typically caused by ABO incompatibility between the donor and recipient blood.
ABO incompatibility is more likely to lead to acute hemolytic reactions.
Allergic reactions are usually triggered by sensitivities to plasma proteins or allergens in the blood product.
Choice E rationale:
Bacterial contamination of blood products can indeed result in sepsis.
This is a severe and life-threatening complication of transfusion, making it important to ensure the safety of blood products and proper handling to prevent contamination.
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