A client is about to receive a blood transfusion, and the nurse is responsible for monitoring the transfusion.
What should the nurse do during the transfusion?
"I'll stay with the patient for the entire transfusion.”
"I'll add medications to the blood bag as needed.”
"I'll administer the transfusion at a rate of 4 mL/min.”
"I'll use any available intravenous line for the transfusion.”
The Correct Answer is A
"I'll stay with the patient for the entire transfusion."
Choice A rationale:
Staying with the patient for the entire transfusion is a crucial safety measure.
The nurse must monitor the patient for any signs of a transfusion reaction, such as fever, chills, rash, shortness of breath, or changes in vital signs.
Immediate intervention may be required if a reaction occurs.
Choice B rationale:
Adding medications to the blood bag is not within the nurse's scope of practice and should not be done without a specific physician's order.
Medications should be administered separately through a different IV line, if necessary, and only as ordered.
Choice C rationale:
Administering the transfusion at a rate of 4 mL/min is not a standard practice.
The rate of transfusion is determined by the physician's order and the patient's specific needs.
It is not a fixed rate and should be adjusted as needed.
Choice D rationale:
Using any available intravenous line for the transfusion may not be appropriate, especially if the line is already in use for other medications or fluids.
The nurse should select a dedicated line for the transfusion to minimize the risk of contamination or complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is B
Explanation
Choice A rationale:
AB+ blood type contains both A and B antigens as well as the Rh antigen (positive)
Blood type O+ has neither A nor B antigens but does have the Rh antigen.
Therefore, AB+ blood cannot be safely transfused to a client with blood type O+ as it would lead to a mismatch in ABO compatibility.
Choice B rationale:
O- blood type is the universal donor for red blood cell transfusions.
It lacks both A and B antigens as well as the Rh antigen, making it compatible with all other blood types.
Since the client in question has blood type O+, which is Rh-positive, O- blood can be safely transfused without any ABO or Rh incompatibility.
Choice C rationale:
A+ blood type contains A antigens and the Rh antigen (positive)
Blood type O+ lacks A antigens but does have the Rh antigen.
Therefore, A+ blood is not compatible with O+ blood due to ABO incompatibility.
Choice D rationale:
B+ blood type contains B antigens and the Rh antigen (positive)
Blood type O+ lacks B antigens but does have the Rh antigen.
Therefore, B+ blood is not compatible with O+ blood due to ABO incompatibility.
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