Before administering a blood transfusion, which action by the nurse is most important?

Chart the procedure in the client’s medical record.

Monitor the client until the pain subsides.

Verify blood product identification.

Review the client’s record for known allergies.

Answer and Explanation

The Correct Answer is C

Choice A reason: Charting is important for documentation but not the priority before transfusion. Verifying blood product identification prevents life-threatening transfusion reactions, such as hemolytic reactions, which can occur from mismatched blood types.
Choice B reason: Monitoring for pain is irrelevant, as pain is not a primary concern during transfusion initiation. Ensuring correct blood product identification prevents severe reactions like hemolysis, which can cause organ damage or death.
Choice C reason: Verifying blood product identification ensures the correct blood type is administered, preventing hemolytic transfusion reactions. Mismatched blood can cause immune-mediated hemolysis, leading to severe complications, including renal failure or shock, making this the priority.
Choice D reason: Reviewing allergies is important but secondary to verifying blood product identification. Allergic reactions are less severe than hemolytic reactions from mismatched blood, which pose immediate life-threatening risks during transfusion.

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Correct Answer is A

Explanation

Choice A reason: Positioning the needle bevel up during IV insertion aligns the sharp edge upward, facilitating smooth vein entry and reducing vessel trauma. This orientation ensures better visualization of the needle tip and minimizes the risk of piercing the vein’s back wall.
Choice B reason: Bevel down or up is not a standard practice, as it lacks specificity. Bevel up is preferred to ensure controlled entry and minimize vein damage. Inconsistent bevel positioning can increase the risk of failed cannulation or hematoma formation.
Choice C reason: Bevel center is not a recognized term in IV insertion. The bevel must be up to optimize vein entry and reduce trauma. Incorrect positioning can lead to vessel perforation or difficulty advancing the catheter, compromising the procedure.
Choice D reason: Bevel down increases the risk of piercing the vein’s back wall, causing hematoma or failed cannulation. Bevel up is the standard to ensure smooth entry, reduce tissue trauma, and facilitate catheter advancement into the vein.

A. Scrub the spike end with alcohol. B. Obtain a new IV bag. C. Obtain new IV tubing. D. Wipe the end of the tubing with Betadine.

Correct Answer is C

Explanation

Choice A reason: Scrubbing the spike with alcohol may not fully sterilize it after contact with a non-sterile surface. Contaminated tubing risks introducing bacteria into the bloodstream, leading to catheter-related infections or sepsis.
Choice B reason: Replacing the IV bag is unnecessary, as the bag was not contaminated. The spike, which contacts the bag’s sterile port, is the compromised component, requiring new tubing to ensure sterility.
Choice C reason: New IV tubing ensures sterility after the spike contacts a non-sterile surface. Contaminated tubing could introduce pathogens into the IV system, causing bloodstream infections. Replacing it maintains the sterile field for safe infusion.
Choice D reason: Wiping with Betadine may not adequately sterilize the spike after contamination. Betadine requires contact time and may leave residue. New tubing is the safest option to prevent infection during IV administration.

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Before administering a blood transfusion, which action by the nurse is most important?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When entering the skin and cannulating a vein, the usual needle position is:

Correct Answer is A

Explanation

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action?

Correct Answer is C

Explanation

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