A nurse is preparing to administer a platelet transfusion to a client with severe thrombocytopenia. The nurse should:
Infuse the platelets slowly over 4 hours.
Use a standard IV infusion set for administration.
Verify compatibility with the client's blood type.
Warm the platelets to room temperature before infusion.
The Correct Answer is C
A. Platelets should be infused rapidly, typically over 30 to 60 minutes, to prevent clotting and ensure effectiveness.
B. A specialized platelet administration set with a filter should be used, not a standard IV infusion set.
C. Although ABO compatibility is less critical for platelets than for red blood cell transfusions, compatibility should still be verified to reduce the risk of reactions.
D. Platelets should not be warmed; they should be stored at room temperature and gently agitated to prevent clumping.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct: The client's symptoms of hives, itching, and facial swelling indicate a potential allergic transfusion reaction (urticarial reaction). The nurse's immediate action is to stop the transfusion immediately and notify the healthcare provider for further evaluation and intervention.
B) Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic transfusion reaction, it is not the immediate action. The nurse should first stop the transfusion and notify the healthcare provider.
C) Incorrect: Slowing down the transfusion rate is not appropriate in the presence of an allergic transfusion reaction. The nurse should stop the transfusion immediately.
D) Incorrect: Placing the client in a supine position with legs elevated is not indicated for an allergic transfusion reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.
Correct Answer is A
Explanation
A) Correct: The nurse should verify the client's identity and blood type with two unique identifiers, such as asking the client to state their full name and date of birth and comparing it to their identification band. This step ensures that the correct blood product is administered to the right client, promoting safety.
B) Incorrect: Confirming the expiration date of the blood product is important but not the first step in ensuring client safety during a blood transfusion. The nurse should first verify the client's identity and blood type.
C) Incorrect: Assessing the client's vital signs is essential, but it is not the first action to be taken. Verifying the client's identity and blood type is the priority before starting the transfusion.
D) Incorrect: Obtaining informed consent from the client is crucial but not the first action to be taken. The nurse should first verify the client's identity and blood type before seeking consent for the transfusion.
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