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. Topical antiseptics, such as hydrogen peroxide or alcohol, can help prevent infection but are safe to use on minor cuts when applied correctly.

B) Correct. Applying direct pressure to the bleeding site for at least 10 minutes helps control minor bleeding and allows the blood to clot, reducing the risk of excessive bleeding.

C) Incorrect. Aspirin is an antiplatelet medication and can increase the risk of bleeding. It should not be used to stop bleeding quickly without medical guidance.

D) Incorrect. Elevating the affected limb above the heart level is not typically necessary for minor bleeding episodes and may not be practical for all bleeding sites.

A. Administering pain medication for comfort. B. Initiating blood transfusion as prescribed. C. Providing emotional support to the client. D. Encouraging deep breathing exercises.

Correct Answer is B

Explanation

A) Incorrect. While pain management is important, it is not the priority in the management of massive hemorrhage and hypovolemia.

B) Correct. The priority intervention for a client experiencing massive hemorrhage and hypovolemia is to initiate a blood transfusion to replace lost blood and improve oxygen-carrying capacity.

C) Incorrect. Emotional support is essential, but it is not the priority in the acute management of hemorrhage and hypovolemia.

D) Incorrect. Deep breathing exercises are not the priority when the client is experiencing massive hemorrhage and requires urgent interventions to stabilize their condition.

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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

A nurse is providing education to a client about self-management of minor bleeding episodes at home. Which instruction should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a client who is experiencing massive hemorrhage. Which intervention should the nurse prioritize to address hypovolemia?

Correct Answer is B

Explanation

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