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 C
Explanation
Choice A rationale:
Delayed hemolytic reaction occurs more than 24 hours after a blood transfusion and is characterized by a drop in hemoglobin levels, jaundice, and a positive direct antiglobulin test (Coombs test)
It does not typically present with fever, rash, and pancytopenia, so it is not the best choice for the given symptoms.
Choice B rationale:
Graft-versus-host disease (GVHD) is a condition where donor T lymphocytes attack the recipient's tissues, often seen in bone marrow or stem cell transplant recipients.
While it can cause pancytopenia, it typically occurs within a few weeks of transplantation, not four weeks after a blood transfusion.
Therefore, it is less likely to be the cause in this scenario.
Choice C rationale:
Transfusion-associated graft-versus-host disease (TA-GVHD) occurs when viable T lymphocytes in the transfused blood attack the recipient's tissues.
Symptoms can include fever, rash, diarrhea, and pancytopenia.
TA-GVHD is a delayed complication of transfusion that typically presents about 1 to 6 weeks post-transfusion, making it the most likely cause of the symptoms described in the scenario.
Choice D rationale:
Post-transfusion purpura is a rare condition that occurs 5 to 12 days after a transfusion and is characterized by sudden severe thrombocytopenia (low platelet count) and bleeding, often in the form of purpura.
It does not typically present with fever, rash, and pancytopenia, so it is not the best choice for the given symptoms.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
Ensuring that blood products meet quality and safety standards is a fundamental aspect of blood transfusion safety.
Blood products must be properly screened and tested for infectious diseases and compatibility to reduce the risk of adverse reactions in the recipient.
Choice B rationale:
Using the right blood product for the right patient at the right time is a critical safety measure.
Administering the wrong blood type or product can lead to severe and life-threatening reactions, such as hemolytic transfusion reactions.
Choice C rationale:
Applying a barcode system or electronic verification system for patient and product identification is essential for ensuring that the correct blood product is matched to the right patient.
This technology helps prevent administration errors.
Choice D rationale:
Administering blood products using reusable equipment is not recommended due to the risk of cross-contamination and infection transmission.
Single-use, disposable equipment is the standard for blood transfusion to enhance safety.
Choice E rationale:
Disposing of used blood products and materials according to hospital policy is crucial to prevent potential contamination and reduce the risk of infection transmission.
Proper disposal procedures are a part of overall transfusion safety protocols.
Choice D is not a recommended safety measure as using reusable equipment for blood transfusions can increase the risk of contamination and transmission of infections.
Therefore, it should not be included as part of blood transfusion safety measures.
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