A nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?

Ensuring the blood is compatible with the client's blood type

Administering the transfusion rapidly

Using a blood warmer to warm the blood prior to transfusion

Administering prophylactic antihistamines before the transfusion

Answer and Explanation

The Correct Answer is A

A. Ensuring the blood is compatible with the client's blood type is critical in preventing an acute hemolytic reaction, as incompatible blood transfusions can cause serious, potentially life-threatening reactions.

B. Administering the transfusion rapidly can increase the risk of complications and does not prevent hemolytic reactions; transfusions should be given at a safe rate based on the client's condition.

C. Using a blood warmer is not a standard intervention to prevent hemolytic reactions; it's typically used in specific cases such as massive transfusions or hypothermia, but it does not address compatibility.

D. Administering prophylactic antihistamines is not a recommended practice to prevent hemolytic reactions; it is more relevant for preventing allergic reactions associated with transfusions.

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Correct Answer is B

Explanation

A. Diarrhea is not a typical finding associated with anemia from blood loss; it may occur for other reasons but is not directly related to low hemoglobin levels.

B. Fatigue is a common symptom in clients with anemia, particularly when hemoglobin levels are low, as there is reduced oxygen delivery to tissues, leading to feelings of weakness and tiredness.

C. Hypertension is unlikely to be present in a client with significant blood loss; instead, hypotension may be more expected due to reduced blood volume.

D. Bradycardia is not typically associated with anemia; in fact, tachycardia (increased heart rate) is more common as the body tries to compensate for reduced oxygen-carrying capacity.

A. Hang a bag of 0.9% normal saline with 5% dextrose at the bedside (D5%NS) B. Verify the client's name and blood type with a second nurse C. Infuse the unit of blood within 4 hours. D. Obtain baseline vital signs prior to starting the transfusion E. Continuously monitor the client during the first 15 minutes of the transfusion F. Insert an 18-gauge intravenous catheter G. Insert a 22-gauge intravenous catheter

Correct Answer is ["B","C","D","E","F"]

Explanation

A. Hanging a bag of 0.9% normal saline with 5% dextrose (D5%NS) is incorrect; only normal saline (0.9% NS) should be used to prime the blood transfusion line to avoid hemolysis.

B. Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions and ensure the correct blood product is given.

C. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth in the blood product.

D. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition and monitor for any changes during the transfusion.

E. Continuously monitoring the client during the first 15 minutes of the transfusion is vital for detecting any signs of a transfusion reaction promptly.

F. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions as it provides a sufficient lumen to accommodate the blood flow.

G. Inserting a 22-gauge intravenous catheter is acceptable for some transfusions, but an 18-gauge is preferred for larger blood products.

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A nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["B","C","D","E","F"]

Explanation

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