A nurse is preparing to administer a blood transfusion to a patient.
Which of the following actions should the nurse take before starting the transfusion?
"I'll select any available intravenous site for the transfusion.”
"I'll use a blood administration set with additives.”
"I'll verify the physician's order for the specific blood product.”
"I'll administer the transfusion as quickly as possible.”
The Correct Answer is C
"I'll verify the physician's order for the specific blood product."
Choice A rationale:
Selecting any available intravenous site for the transfusion without verifying the physician's order is unsafe and can lead to administering the wrong blood product or causing an adverse reaction in the patient.
Verifying the order is a critical step in ensuring patient safety during a blood transfusion.
Choice B rationale:
Using a blood administration set with additives may be necessary in some cases, but it is not the primary action the nurse should take before starting the transfusion.
Verifying the physician's order is the first and most crucial step.
Choice C rationale:
Verifying the physician's order for the specific blood product is essential to confirm that the correct blood type and unit are being administered to the patient.
This step ensures ABO and Rh compatibility and minimizes the risk of transfusion reactions.
Choice D rationale:
Administering the transfusion as quickly as possible is not appropriate and can be dangerous.
Transfusions should be administered at a controlled and appropriate rate to monitor for any adverse reactions.
Rushing the transfusion can increase the risk of complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Lactated Ringer's solution is a volume expander, not a therapy for improving oxygen-carrying capacity.
It can increase blood volume but does not address the underlying cause of anemia or hypoxia.
Choice B rationale:
Hemostatic agents like protamine sulfate are used to reverse the anticoagulant effects of heparin.
They are not indicated for improving oxygen-carrying capacity in anemic patients.
Choice C rationale:
Oxygen therapy delivered through a nasal cannula or mask is indeed a therapy to enhance oxygen-carrying capacity.
It provides supplemental oxygen to improve oxygen saturation in the blood, which can alleviate hypoxia in anemic patients.
Choice D rationale:
Erythropoietin injections can stimulate the production of red blood cells in the bone marrow.
This therapy can increase the patient's hemoglobin levels and improve oxygen-carrying capacity, making it a suitable recommendation for a patient with hypoxia due to anemia.
For , choices A, C, and D are correct as they are examples of volume expanders that can increase blood volume and circulation without adding blood cells.
For , choice C is correct as hemostatic agents like vitamin K or tranexamic acid can promote clotting and stop bleeding in a patient with a bleeding disorder.
For , choice D is correct as erythropoietin injections can stimulate the production of red blood cells and help alleviate hypoxia in a patient with anemia.
Correct Answer is A
Explanation
Choice A rationale:
Delayed hemolytic reactions occur several days after a blood transfusion and are characterized by symptoms like fever, jaundice, hemoglobinuria, and a positive Coombs test.
This matches the patient's presentation described in the question.
Choice B rationale:
Transfusion-associated graft-versus-host disease (TA-GVHD) typically presents with fever, rash, diarrhea, and liver dysfunction.
It is a rare but severe complication that occurs when the donor's lymphocytes attack the recipient's tissues.
Choice C rationale:
Post-transfusion purpura is a rare condition characterized by severe thrombocytopenia (low platelet count) that occurs a week or more after a blood transfusion.
It does not match the symptoms described in the question.
Choice D rationale:
Transfusion-related immunomodulation (TRIM) is a theoretical concept and not a recognized clinical entity.
It is not associated with the specific symptoms mentioned in the question.
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