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

Explanation

A) Correct: Red blood cells are the main blood component involved in the crossmatching process. Crossmatching ensures compatibility between the donor's red blood cells and the recipient's plasma, preventing adverse reactions during the transfusion.

B) Incorrect: White blood cells are not part of the crossmatching process. They play a role in the immune response but are not specifically assessed during crossmatching.

C) Incorrect: Platelets are not directly involved in the crossmatching process. Crossmatching primarily focuses on red blood cell compatibility.

D) Incorrect: Plasma is not directly involved in the crossmatching process. The focus is on ensuring compatibility between red blood cells and the recipient's plasma.

A. Obtain a signed informed consent from the client. B. Confirm the client's blood type and Rh factor with two unique identifiers. C. Ensure that the blood product is properly labeled and has not expired. D. Assess the client's vital signs and baseline laboratory values.

Correct Answer is B

Explanation

A) Incorrect: Obtaining a signed informed consent is an essential step before administering a blood transfusion, but it is not the priority action for preventing a potential complication related to blood compatibility. The nurse should first confirm the client's blood type and Rh factor.

B) Correct: The nurse's priority action is to confirm the client's blood type and Rh factor with two unique identifiers to ensure compatibility between the client and the blood product. This step is crucial for preventing transfusion reactions due to ABO and Rh incompatibility.

C) Incorrect: Ensuring that the blood product is properly labeled and has not expired is important for patient safety but is not the priority action before administering a blood transfusion. The nurse should first confirm the client's blood type and Rh factor.

D) Incorrect: Assessing the client's vital signs and baseline laboratory values is essential, but it is not the priority action for preventing a potential complication related to blood compatibility. The nurse should first confirm the client's blood type and Rh factor.

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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 crossmatch blood for a client who requires a blood transfusion. Which blood component is involved in the crossmatching process?

Correct Answer is A

Explanation

A nurse is preparing to administer a blood transfusion to a client. What is the nurse's priority action to prevent a potential complication related to blood compatibility?

Correct Answer is B

Explanation

A nurse is providing post-transfusion care to a client who just received a blood transfusion. Which assessment finding should the nurse report to the healthcare provider immediately?

A nurse is caring for a client with severe hypoalbuminemia. Which blood product should the nurse anticipate being prescribed to address the client's condition?

A nurse is monitoring a client who just received a blood transfusion. The client suddenly develops dyspnea, tachycardia, and chest pain. What is the nurse's priority action?

A nurse is caring for a client who experienced a mild allergic reaction during a blood transfusion. Which action should the nurse take to prevent future allergic reactions in this client?

A client with severe liver disease has a decreased ability to synthesize clotting factors. Which blood product should the nurse anticipate being prescribed to manage the client's condition?

A client has a history of severe allergic reactions and is scheduled to receive a blood transfusion. What intervention should the nurse implement to prevent an allergic transfusion reaction in this client?

A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?

A nurse is preparing to crossmatch blood for a client with blood type O-positive(O+). Which blood type can safely receive blood from this client?