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:
Oxygen therapy can improve oxygen-carrying capacity but does not directly address chronic anemia due to kidney disease.
Erythropoietin therapy is a more targeted option.
Choice B rationale:
Erythropoietin injections stimulate red blood cell production and can be effective in treating anemia associated with chronic kidney disease.
It is a suitable alternative to blood transfusion in this context.
Choice C rationale:
Volume expanders like lactated Ringer's primarily increase blood volume and circulation but do not address anemia or increase hemoglobin levels.
This option may not be the most appropriate for the client's condition.
Choice D rationale:
Iron therapy is generally used to treat iron deficiency anemia, but it may not be the most effective option for anemia related to chronic kidney disease, as it does not address the underlying cause.
Erythropoietin therapy is a more targeted approach.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
Normal saline is a sterile solution of sodium chloride in water, and it is a commonly used intravenous fluid to expand blood volume.
It is isotonic, meaning it has a similar osmolarity to blood, and can effectively increase circulating blood volume without adding blood cells.
Choice C rationale:
Albumin is a colloid solution often used as a volume expander.
It contains proteins that help maintain colloid osmotic pressure, which can draw fluid from interstitial spaces into the bloodstream, thereby increasing blood volume and circulation without adding blood cells.
Choice D rationale:
Hydroxyethyl starch (HES) is another colloid solution used as a volume expander.
It works similarly to albumin by increasing colloid osmotic pressure and attracting fluid into the vascular space, thereby increasing blood volume and circulation without adding blood cells.
Choice B rationale:
Erythropoietin (EPO) is a hormone that stimulates the production of red blood cells in the bone marrow.
It does not directly increase blood volume or circulation; instead, it increases the number of red blood cells, which can improve oxygen-carrying capacity in the long term but does not serve as a volume expander.
Choice E rationale:
Oxygen therapy is not a volume expander.
While it can increase the oxygen-carrying capacity of the blood by providing supplemental oxygen, it does not increase blood volume or circulation and is not used for that purpose.
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