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 B
Explanation
Choice A rationale:
"I'm feeling weak and dizzy." Rationale: Weakness and dizziness can be symptoms of anemia, which is often associated with low hemoglobin levels.
However, these symptoms alone are not a definitive indication for blood transfusion.
Other factors, such as the patient's overall clinical condition and the cause of the low hemoglobin, need to be considered.
Choice B rationale:
"My hemoglobin is 7 g/dL, so I need a transfusion." Rationale: This statement indicates that the patient is aware of their low hemoglobin level and believes they need a transfusion.
The hemoglobin level of 7 g/dL is a common threshold used as an indication for blood transfusion, especially in symptomatic patients.
This choice is correct because it aligns with the appropriate clinical indication for a transfusion based on the hemoglobin level.
Choice C rationale:
"I had orthopedic surgery yesterday." Rationale: While surgery can lead to blood loss, the statement alone does not provide sufficient information to determine if a transfusion is necessary.
The decision to transfuse blood should be based on the patient's hemoglobin level, overall clinical condition, and the extent of blood loss during surgery.
Choice D rationale:
"I have a stable cardiovascular disease." Rationale: The presence of stable cardiovascular disease is not directly related to the need for a blood transfusion based on a hemoglobin level of 7 g/dL.
The decision to transfuse should primarily be based on the patient's hemoglobin level and symptoms.
Correct Answer is C
Explanation
Choice A rationale:
Choosing a site with infiltration or phlebitis is not appropriate for a blood transfusion.
Infiltration can lead to the transfused blood leaking into the surrounding tissues, and phlebitis can cause discomfort and complications.
A suitable site should be chosen for the transfusion.
Choice B rationale:
Using the same IV line for other medications without flushing it between medications can lead to drug interactions or contamination.
It is generally not recommended to mix blood transfusions with other medications in the same line.
Choice C rationale:
Avoiding sites with edema or infection is a crucial consideration when selecting an intravenous site for a blood transfusion.
Using a site with edema can make it difficult to insert the catheter, and using a site with infection can introduce pathogens into the bloodstream.
Choice D rationale:
Using a 24-gauge IV catheter for a blood transfusion may not be suitable for all patients.
The size of the catheter should be appropriate for the type of blood product being transfused and the patient's vein size.
A larger catheter may be necessary for blood products with higher viscosity.
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