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 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.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.