A nurse is preparing to initiate a blood transfusion for a client. Which action should the nurse take first to ensure client safety?

Verify the client's identity and blood type with two unique identifiers.

Confirm the expiration date of the blood product.

Assess the client's vital signs, including temperature, pulse, and blood pressure.

Obtain informed consent from the client for the blood transfusion.

Answer and Explanation

The Correct Answer is A

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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Correct Answer is A

Explanation

A) Correct: Red blood cells are the main blood component involved in the crossmatching process. Crossmatching ensures compatibility between the donor's red blood cells and the recipient's plasma, preventing adverse reactions during the transfusion.

B) Incorrect: White blood cells are not part of the crossmatching process. They play a role in the immune response but are not specifically assessed during crossmatching.

C) Incorrect: Platelets are not directly involved in the crossmatching process. Crossmatching primarily focuses on red blood cell compatibility.

D) Incorrect: Plasma is not directly involved in the crossmatching process. The focus is on ensuring compatibility between red blood cells and the recipient's plasma.

A. Administering antipyretics to reduce fever. B. Preparing to administer a diuretic to manage fluid overload. C. Monitoring the client's vital signs frequently. D. Administering epinephrine to counteract an allergic reaction.

Correct Answer is C

Explanation

A) Incorrect: Administering antipyretics to reduce fever is not the appropriate intervention for an acute hemolytic transfusion reaction. This type of reaction involves the destruction of red blood cells, not an elevation in body temperature.

B) Incorrect: Preparing to administer a diuretic is not the appropriate intervention for an acute hemolytic transfusion reaction. Fluid overload is not a typical feature of this type of reaction.

C) Correct: Monitoring the client's vital signs frequently is a crucial intervention for an acute hemolytic transfusion reaction. This type of reaction can cause rapid onset of severe symptoms, including fever, chills, hypotension, tachycardia, and potential shock.

D) Incorrect: Administering epinephrine is not the appropriate intervention for an acute hemolytic transfusion reaction. Epinephrine is used to treat anaphylactic reactions, not hemolytic reactions.

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A nurse is preparing to initiate a blood transfusion for a client. Which action should the nurse take first to ensure client safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to crossmatch blood for a client who requires a blood transfusion. Which blood component is involved in the crossmatching process?

Correct Answer is A

Explanation

A nurse is caring for a client who experiences an acute hemolytic transfusion reaction. What intervention should the nurse anticipate implementing?

Correct Answer is C

Explanation

A client receiving a blood transfusion develops sudden chest pain, dyspnea, and a productive cough with pink, frothy sputum. The nurse suspects a severe transfusion reaction. What is the nurse's immediate action?

A client who received a blood transfusion 2 hours ago is now experiencing symptoms of a transfusion reaction, including fever, chills, and shortness of breath. What is the nurse's priority action?

A nurse is monitoring a client who just received a blood transfusion. The client suddenly develops dyspnea, tachycardia, and chest pain. What is the nurse's priority action?

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A client with blood type AB-positive (AB+) requires a blood transfusion. Which blood types can safely donate to this client?

A nurse is caring for a client who experienced a mild allergic reaction during a blood transfusion. Which action should the nurse take to prevent future allergic reactions in this client?