A nurse is preparing to administer a blood transfusion to a client with significant blood loss. What is the nurse's most important action before starting the transfusion?

Check the client's blood pressure.

Verify the client's identification using two identifiers.

Assess the client's oxygen saturation level.

Obtain consent for the blood transfusion.

Answer and Explanation

The Correct Answer is B

A) Incorrect. Checking the client's blood pressure is important but not the most critical action before starting a blood transfusion.

B) Correct. The most crucial step before administering any intervention, including a blood transfusion, is to verify the client's identification using two identifiers (e.g., name and date of birth or medical record number) to ensure the right blood is given to the right client.

C) Incorrect. While assessing the client's oxygen saturation is important, it is not the priority before starting a blood transfusion.

D) Incorrect. Obtaining consent for the blood transfusion is essential, but verifying the client's identification is more critical before administering the transfusion.

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Correct Answer is B

Explanation

A) Incorrect. While hypertension can be a risk factor for cardiovascular issues, it is not directly associated with an increased risk of hemorrhage.

B) Correct. Anticoagulant medication can interfere with the body's clotting mechanisms, making the client more susceptible to bleeding and hemorrhage.

C) Incorrect. Being a regular blood donor does not inherently increase the risk of hemorrhage unless the client donates too frequently, leading to anemia.

D) Incorrect. Having a balanced diet is essential for overall health, but it is not a specific risk factor for hemorrhage.

A. Bradycardia B. Hypotension C. Pallor D. Restlessness

Correct Answer is D

Explanation

A) Incorrect. Bradycardia is not typically an early clinical manifestation of hemorrhage. The body may initially compensate for the blood loss by increasing heart rate (tachycardia).

B) Incorrect. Hypotension may occur later in the course of hemorrhage as blood loss progresses, but it is not an early manifestation.

C) Incorrect. Pallor (pale skin) may occur later as a result of decreased blood volume, but it is not an early sign.

D) Correct. Restlessness and anxiety are early manifestations of hemorrhage, reflecting the body's compensatory response to maintain perfusion in the early stages of blood loss.

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A nurse is preparing to administer a blood transfusion to a client with significant blood loss. What is the nurse's most important action before starting the transfusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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