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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
"I'll verify the physician's order for the specific blood product."
Choice A rationale:
Selecting any available intravenous site for the transfusion without verifying the physician's order is unsafe and can lead to administering the wrong blood product or causing an adverse reaction in the patient.
Verifying the order is a critical step in ensuring patient safety during a blood transfusion.
Choice B rationale:
Using a blood administration set with additives may be necessary in some cases, but it is not the primary action the nurse should take before starting the transfusion.
Verifying the physician's order is the first and most crucial step.
Choice C rationale:
Verifying the physician's order for the specific blood product is essential to confirm that the correct blood type and unit are being administered to the patient.
This step ensures ABO and Rh compatibility and minimizes the risk of transfusion reactions.
Choice D rationale:
Administering the transfusion as quickly as possible is not appropriate and can be dangerous.
Transfusions should be administered at a controlled and appropriate rate to monitor for any adverse reactions.
Rushing the transfusion can increase the risk of complications.
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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