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 A

Explanation

The client is showing signs of fluid overload due to heart failure exacerbation, including:

Progressive shortness of breath (fluid in the lungs)
Jugular venous distention (JVD) (increased central venous pressure)
Crackles in the lung bases (pulmonary congestion/edema)
Bounding pulse (increased circulating volume)

IV diuretics (e.g., Furosemide/Lasix) are the first-line treatment to rapidly reduce fluid overload by promoting diuresis and decreasing pulmonary congestion.

A. "The procedure can help determine whether your stroke was caused by a clot or by bleeding B. The procedure can help identify which part of the brain seizure activity is coming from. C. "The procedure helps evaluate nerve function to your extremities D. The procedure shows images of your heart’s electrical activity.'

Correct Answer is B

Explanation

A) "The procedure can help determine whether your stroke was caused by a clot or by bleeding": This statement is incorrect. An electroencephalogram (EEG) is a diagnostic test used to evaluate the electrical activity of the brain, not to assess stroke-related causes. To determine whether a stroke was caused by a clot or bleeding, imaging studies like a CT scan or MRI are typically used, not an EEG.

B) "The procedure can help identify which part of the brain seizure activity is coming from": This is the correct response. An EEG records electrical activity in the brain and is primarily used to diagnose and monitor conditions such as seizures, epilepsy, and sleep disorders. It can help pinpoint the area of the brain where abnormal electrical activity, such as that seen in seizures, is originating. This makes it an invaluable tool for understanding seizure disorders.

C) "The procedure helps evaluate nerve function to your extremities": This statement is inaccurate. An EEG does not assess nerve function to the extremities. Tests like nerve conduction studies or electromyography (EMG) are used to evaluate peripheral nerve function, whereas an EEG specifically measures electrical activity in the brain.

D) "The procedure shows images of your heart’s electrical activity": This statement is incorrect. An EEG measures brain electrical activity, not the heart's. To assess the heart's electrical activity, an electrocardiogram (ECG or EKG) is used. Therefore, an EEG and an ECG serve very different purposes.

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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

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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