A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?
The first 2 min
The final 2 min
The final 15 min
The first 15 min
The Correct Answer is D
A. The first 2 min - This is too short a period to monitor effectively for transfusion reactions.
B. The final 2 min - Transfusion reactions are more likely to occur at the beginning of the transfusion rather than at the end.
C. The final 15 min - While it’s still important to monitor, reactions are most likely to be detected earlier in the infusion.
D. The first 15 min - Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for any signs of a reaction, such as fever, chills, rash, or difficulty breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Hemolytic: Acute hemolytic transfusion reactions can occur quickly after starting a transfusion and present with symptoms such as fever, chills, headache, low back pain, tachycardia, and apprehension. It is a serious reaction caused by the destruction of transfused red blood cells.
B. Allergic: Allergic reactions to blood transfusions typically present with hives, itching, and anaphylaxis, not low back pain or tachycardia.
C. Febrile: Febrile reactions involve fever and chills but not typically headache or back pain.
D. Bacterial: Bacterial contamination of blood can cause fever and chills, but not specifically the symptoms of headache and low back pain described.
Correct Answer is B
Explanation
A. There is an elevated number of immature thrombocytes - Thrombocytes are platelets, and a shift to the left does not refer to these.
B. There is an elevated number of immature neutrophils (bands) - A "shift to the left" typically refers to an increase in immature neutrophils, also known as bands, in the blood. This often indicates an acute infection or inflammation as the body is producing and releasing more neutrophils to fight an infection.
C. There is an elevated number of mature neutrophils (segs) - An elevated number of mature neutrophils (segmented neutrophils) does not indicate a shift to the left. The term specifically refers to immature forms.
D. There is an elevated number of mature erythrocytes - Mature erythrocytes are red blood cells, and a shift to the left does not pertain to red blood cell counts or maturity.
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