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) "Complete blood count (CBC)":
. A CBC can provide important information about the patient's overall health, including potential signs of infection, anemia, or other underlying conditions. However, in the context of acute neurological symptoms such as left-sided weakness, CT scan is the priority test because it will help quickly determine if there is an acute neurological event, such as a stroke or hemorrhage. While a CBC might be useful later to assess for underlying
conditions or potential causes, it is not the first test to perform in this scenario.

B) "Electroencephalogram (EEG)":
. An EEG is primarily used to diagnose and assess seizure activity or epileptic disorders. While seizures can cause neurological deficits, the patient's sudden onset of left-sided weakness is more suggestive of a stroke, not a seizure. The priority is to rule out stroke with a CT scan, not to assess for seizures with an EEG.

C) "Computed tomography (CT) scan":
. A CT scan is the first diagnostic test to perform in patients with acute neurological deficits such as sudden-onset weakness, especially when a stroke is suspected. A CT scan can quickly detect if the cause is an ischemic stroke (lack of blood flow due to a clot) or a hemorrhagic stroke (bleeding in the brain). Time is critical in the management of stroke, as early intervention with treatments like tPA (tissue plasminogen activator) for ischemic stroke can greatly improve outcomes. The CT scan can help determine if the patient is a candidate for thrombolysis or if other interventions are needed.

D) "Chest radiograph (chest x-ray)":
. While a chest x-ray can be useful for diagnosing respiratory issues, such as pneumonia or congestion, it is not helpful in evaluating the cause of acute neurological symptoms like left-sided weakness. The priority test is a CT scan to evaluate the brain and rule out conditions like stroke or hemorrhage, not a chest x-ray.

A. Leave the com to pull the fire alarm B. Remove the client from their room and relocate there to a safe space C. Douse the client with a fire extinguisher, using a back-and-forth motion D. Close all the doors to the client's room

Correct Answer is B

Explanation

A) Leave the room to pull the fire alarm: While pulling the fire alarm is an important step in alerting others to the fire, it is not the nurse's priority action when a fire is discovered in the client's bathroom. The immediate concern is the safety of the client. The nurse should prioritize getting the client out of harm’s way before any other actions.

B) Remove the client from their room and relocate to a safe space: This is the most appropriate first action. The nurse’s first responsibility is to ensure the client's safety. Removing the client from the immediate danger zone, which is the room with the fire, is the priority. This action helps prevent injury or death from smoke inhalation or burns. Once the client is safe, the nurse can then proceed to alert others and address the fire as needed.

C) Douse the client with a fire extinguisher, using a back-and-forth motion: This action is inappropriate because the client should never be doused with a fire extinguisher. The fire extinguisher is intended for controlling the fire, not for use on individuals. Additionally, extinguishing a fire should not take priority over ensuring the client's immediate safety by removing them from the room.

D) Close all the doors to the client's room: Closing doors can help contain the fire and prevent it from spreading, but it is not the first priority. The immediate action should focus on removing the client from the room to a safe space. After ensuring the client's safety, the nurse can then close the doors to help contain the fire while awaiting assistance.Top of FormBottom of Form

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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

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