A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client with severe anemia. Before starting the blood transfusion, the nurse should:
Obtain the client's informed consent for the blood transfusion.
Confirm the client's blood type and Rh factor with the blood bank.
Administer pre-medication to prevent transfusion reactions.
Assess the client's blood pressure and heart rate.
Correct Answer : A,B,D
A) Obtaining the client's informed consent is a critical step before any medical procedure, including blood transfusions. This ensures the client understands the risks and benefits of the transfusion and gives their consent willingly.
B) Confirming the client's blood type and Rh factor with the blood bank is essential to prevent transfusion reactions. Mismatching blood types can lead to severe transfusion reactions and is a crucial step in the transfusion process.
C) Administering pre-medication to prevent transfusion reactions is not a standard practice. However, the nurse should assess the client for any risk factors or history of previous transfusion reactions to take appropriate precautions.
D) Assessing the client's blood pressure and heart rate is an important part of the overall assessment before the blood transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect: A mild headache is a common and expected side effect of a blood transfusion and may not require immediate reporting to the healthcare provider.
B) Correct: A slightly elevated temperature in a client who received a blood transfusion 2 hours ago could indicate a delayed transfusion reaction. The nurse should report this finding to the healthcare provider for further evaluation.
C) Incorrect: Pale and cool skin may be an expected finding in a client who received a blood transfusion, especially if they experienced a rapid transfusion or had a reaction. However, it is not the priority finding to report.
D) Incorrect: Generalized muscle weakness may occur for various reasons and may not be directly related to a delayed transfusion reaction. The nurse should prioritize reporting the slightly elevated temperature.
Correct Answer is C
Explanation
A) Incorrect: Warming the blood product in a microwave oven is not an appropriate action and could lead to hemolysis of the blood components. Blood should be warmed using an approved blood warmer designed for this purpose.
B) Incorrect: Administering a discolored blood product or one containing clots is unsafe and could cause harm to the client. The nurse should not proceed with the administration and should take appropriate actions.
C) Correct: If the nurse discovers that the blood product is discolored or contains clots, the nurse should discard the blood product appropriately and notify the blood bank immediately. This will ensure that the client receives a safe and suitable blood product for the transfusion.
D) Incorrect: Filtering the blood product through a standard IV filter is not sufficient to remove any clots present in the blood product. Using a blood product that appears abnormal could lead to adverse reactions in the client, so it is essential to obtain a replacement from the blood bank.
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