Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to ensure patient safety?

Check the identifying information on the unit of blood against the patient’s ID bracelet

Stay with the patient for 60 minutes after starting the transfusion

Add the blood transfusion as a secondary line to the existing IV.

Prime new primary IV tubing with lactated Ringer's Solution to use for the transfusion

Answer and Explanation

The Correct Answer is A

A) Check the identifying information on the unit of blood against the patient’s ID bracelet:
This is the highest priority to ensure patient safety before beginning a transfusion. The risk of transfusion reactions, including hemolytic reactions due to mismatched blood, makes verifying patient identification critical. The nurse must match the blood product with the patient’s information and confirm that the blood product is correct for the patient. This verification is typically done with a second nurse to ensure safety. If the blood is mismatched, it can lead to severe, potentially life-threatening consequences.

B) Stay with the patient for 60 minutes after starting the transfusion:
While it is important to stay with the patient during the transfusion and monitor for adverse reactions, the highest priority before starting the transfusion is verifying patient and blood product compatibility. After starting the transfusion, staying with the patient for the first 15 minutes is critical for monitoring for early signs of a transfusion reaction, but this action occurs after the blood has been correctly matched and started.

C) Add the blood transfusion as a secondary line to the existing IV:
Ensuring proper identification and blood product matching is more critical than deciding whether to use a secondary IV line. The nurse should verify patient and blood compatibility first and then proceed with setting up the IV line for transfusion.

D) Prime new primary IV tubing with lactated Ringer's solution to use for the transfusion:
Priming IV tubing with lactated Ringer’s solution is incorrect for a blood transfusion. Blood should only be administered with normal saline, as other fluids, including lactated Ringer's solution, can cause clotting or hemolysis when mixed with blood products. This action would not be a safe or appropriate step in preparing for a blood transfusion. The correct solution to prime tubing for blood transfusions is normal saline, and this is secondary to ensuring proper patient identification and blood compatibility.

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Correct Answer is C

Explanation

A) Remove the traction when the client wants to ambulate:
Traction is a therapeutic treatment used to immobilize bones, joints, or soft tissues, often after fractures or orthopedic procedures. Removing traction to allow ambulation is not appropriate unless directed by a healthcare provider. Traction must be maintained to ensure proper alignment and healing of the affected body part. Premature removal can cause complications such as malalignment, delayed healing, or further injury.

B) Provide pin site care for skin traction:
Pin site care is required for skeletal traction, not skin traction. Skin traction uses adhesive strips or other external devices to apply force to the body, and no pins are involved. Skeletal traction, on the other hand, uses pins, screws, or wires that are inserted directly into the bone. It’s important to provide proper pin site care to prevent infection in skeletal traction, but this is not relevant to skin traction, which doesn’t involve direct penetration of the skin.

C) Check the weights to ensure that they are hanging freely:
It is essential to check that the weights in traction are hanging freely and not in contact with the floor or any other surface. Weights should be unobstructed to provide continuous, even force that maintains the proper alignment of the injured body part. Any obstruction or improper positioning of the weights can compromise the effectiveness of the traction and delay healing.

D) Adjust the amount of weight depending on the client’s preference:
The amount of weight used in traction is determined by the healthcare provider based on the specific injury or condition being treated. Adjusting the weight based on the client's preference could lead to inappropriate tension, worsening the injury or hindering the healing process. The nurse should not adjust the weight without a physician’s order, as it is critical to follow the prescribed treatment plan for optimal healing and safety.

A. 15-30g oral carbohydrates. B. 10% dextrose continuous IV infusion C. Glucagon PO, D. 50% dextrose in water (050W) IV push

Correct Answer is D

Explanation

A. 15-30g oral carbohydrates:
Oral carbohydrates are a first-line treatment for hypoglycemia in a conscious, alert patient who can safely swallow. However, since the patient is unresponsive, administering oral carbohydrates is not an appropriate option. The patient’s inability to swallow safely increases the risk of aspiration, making IV treatment the priority in this case.

B. 10% dextrose continuous IV infusion:
A 10% dextrose IV infusion can be used in the management of hypoglycemia, but in an acute, emergency setting where the patient is unresponsive and their blood glucose is critically low (30 mg/dL), a rapid-acting intervention is needed. A bolus dose of a concentrated solution, such as 50% dextrose, is more appropriate for quickly raising the blood glucose level in this situation, rather than a continuous infusion, which takes longer to achieve an effective increase in glucose.

C. Glucagon PO:
Glucagon is typically used for hypoglycemia in patients who are unconscious or unable to take oral glucose. However, glucagon is typically administered intramuscularly (IM) or subcutaneously (SQ), not orally (PO). Administering glucagon orally is ineffective, as it would not be absorbed by the body in the necessary manner to correct hypoglycemia. Therefore, this option is inappropriate.

D. 50% dextrose in water (50% DW) IV push:
When a patient is unresponsive and their blood glucose level is critically low (30 mg/dL), the priority treatment is an immediate, concentrated source of glucose. Administering 50% dextrose IV push is the most appropriate intervention in this scenario. It provides a rapid and effective increase in blood glucose levels, which is critical for reversing hypoglycemia in an emergency situation. This is the fastest and most direct approach to treating severe hypoglycemia in an unresponsive patient.

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Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to ensure patient safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assigned to care for a client in traction. The nurse creates a plan of a care for the client and would include which action in the pian?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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