A nurse is preparing to administer a blood transfusion to a client. Which action should the nurse take before initiating the transfusion?

Confirm the client's identity and blood type with the client's family member.

Obtain informed consent from the client and ensure the client has a signed consent form.

Warm the blood unit to body temperature in a microwave oven to prevent hypothermia.

Administer a rapid bolus of normal saline to prime the client's veins.

Answer and Explanation

The Correct Answer is B

A) Incorrect: Confirming the client's identity and blood type with the client's family member is not a reliable method for ensuring patient safety during a blood transfusion. The nurse should directly verify the client's identity and blood type with two unique identifiers, such as asking the client to state their full name and date of birth and comparing it to their identification band.

B) Correct: Obtaining informed consent from the client is a crucial step before initiating a blood transfusion. The nurse must ensure the client understands the risks and benefits of the transfusion and has willingly provided consent. A signed consent form is the formal documentation of this process.

C) Incorrect: Warming blood in a microwave oven is not an appropriate method for preventing hypothermia and can lead to hemolysis of the blood components. Blood should be warmed using an approved blood warmer designed for this purpose.

D) Incorrect: Administering a rapid bolus of normal saline is unnecessary and could lead to fluid overload in the client. The nurse should administer normal saline or another appropriate IV fluid at the prescribed rate if the client requires hydration before or after the transfusion, but not as a priming method.

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Correct Answer is ["A","B","D"]

Explanation

A) Obtaining the client's informed consent is a critical step before any medical procedure, including blood transfusions. This ensures the client understands the risks and benefits of the transfusion and gives their consent willingly.

B) Confirming the client's blood type and Rh factor with the blood bank is essential to prevent transfusion reactions. Mismatching blood types can lead to severe transfusion reactions and is a crucial step in the transfusion process.

C) Administering pre-medication to prevent transfusion reactions is not a standard practice. However, the nurse should assess the client for any risk factors or history of previous transfusion reactions to take appropriate precautions.

D) Assessing the client's blood pressure and heart rate is an important part of the overall assessment before the blood transfusion.

A. "You may experience a mild fever and chills during the transfusion, which is normal." B. "If you develop any itching, rash, or facial swelling, please notify me immediately." C. "Expect a brief period of increased heart rate after the transfusion is completed." D. "It is common to have lower back pain after receiving a blood transfusion."

Correct Answer is B

Explanation

A) Incorrect: Fever and chills during a blood transfusion may be signs of a febrile transfusion reaction, not an allergic reaction. The nurse should provide information specific to preventing allergic reactions.

B) Correct: Itching, rash, and facial swelling are common signs of an allergic transfusion reaction. The nurse should instruct the client to notify the healthcare provider immediately if they experience these symptoms.

C) Incorrect: A brief period of increased heart rate after the transfusion may be normal, but it is not specific to preventing an allergic transfusion reaction. The nurse should focus on providing information about allergic reaction symptoms.

D) Incorrect: Lower back pain is not typically associated with allergic transfusion reactions. The nurse should provide information about symptoms that indicate an allergic reaction, such as itching, rash, and facial swelling.

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A nurse is preparing to administer a blood transfusion to a client. Which action should the nurse take before initiating the transfusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client with severe anemia. Before starting the blood transfusion, the nurse should:

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is B

Explanation

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