A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?
Administer the blood transfusion slowly to observe for any reactions.
Discontinue the blood transfusion immediately and return the blood to the blood bank.
Increase the infusion rate to flush out the incompatibility.
Mix the incompatible blood with normal saline before transfusion.
The Correct Answer is B
A) Incorrect: Administering the blood transfusion when agglutination and incompatibility are detected is unsafe and may lead to severe transfusion reactions. The nurse should not proceed with the transfusion.
B) Correct: In the presence of agglutination and incompatibility between the donor's red blood cells and the client's plasma, the nurse must discontinue the blood transfusion immediately and return the blood to the blood bank. This ensures the client's safety and prevents further adverse reactions.
C) Incorrect: Increasing the infusion rate will not resolve the incompatibility issue and may worsen the client's condition. The nurse should stop the transfusion promptly.
D) Incorrect: Mixing the incompatible blood with normal saline will not resolve the incompatibility issue and is not a safe practice. The nurse should not proceed with the transfusion and should return the blood to the blood bank.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. AB-positive (AB+) individuals are universal recipients for red blood cells and can safely receive blood from an O-positive (O+) donor.
B. B-negative (B-) individuals require type B or O blood but must receive Rh-negative blood to avoid incompatibility.
C. A-negative (A-) individuals require type A or O blood and must receive Rh-negative blood.
D. AB-negative (AB-) individuals require type AB, A, B, or O blood but must receive Rh-negative blood to prevent a reaction.
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