A nurse is caring for a patient who has received a blood transfusion.
What action should the nurse take to ensure transfusion safety during administration?
Verify the patient's identification only.
Maintain aseptic technique and infection control practices.
Administer blood products using old and sterile equipment.
Monitor the patient's condition only after the transfusion.
The Correct Answer is B
Choice A rationale:
Verifying the patient's identification is an essential step in patient safety, but it alone does not ensure transfusion safety.
Transfusion safety involves multiple steps beyond identification.
Choice B rationale:
Maintaining aseptic technique and infection control practices is crucial during a blood transfusion.
This includes using sterile equipment, wearing gloves, and following proper hand hygiene.
Infection can be a severe complication of transfusion if proper precautions are not taken.
Choice C rationale:
Administering blood products using old and sterile equipment is not a safe practice.
Blood transfusions require the use of fresh, sterile equipment to prevent contamination and ensure patient safety.
Choice D rationale:
Monitoring the patient's condition only after the transfusion is not sufficient to ensure safety.
Continuous monitoring during the transfusion is necessary to detect and respond to any adverse reactions promptly.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Acute hemolytic reaction.
Choice A rationale:
A febrile nonhemolytic reaction typically presents with fever, chills, and rigors but is not associated with back pain, chest pain, dyspnea, or jaundice.
It is often caused by antibodies to leukocytes or platelets in the donor's blood.
This reaction is usually mild and self-limiting.
Choice B rationale:
Allergic reactions typically present with symptoms like urticaria, pruritus, flushing, and can include mild to moderate fever, but they do not cause back pain, chest pain, dyspnea, or jaundice.
These reactions are usually associated with sensitivity to plasma proteins or allergens in the blood product.
Choice C rationale:
Acute hemolytic reactions involve the rapid destruction of red blood cells, leading to the release of hemoglobin into the bloodstream.
This can cause fever, chills, back pain, chest pain, dyspnea, and jaundice, making it the most likely reaction in this case.
It is usually due to ABO incompatibility between the donor and recipient blood.
Choice D rationale:
Transfusion-associated circulatory overload (TACO) typically presents with symptoms related to volume overload, such as pulmonary edema, hypertension, and tachycardia.
It does not typically manifest with fever, chills, back pain, chest pain, dyspnea, or jaundice.
Correct Answer is B
Explanation
Choice A rationale:
"I'm feeling weak and dizzy." Rationale: Weakness and dizziness can be symptoms of anemia, which is often associated with low hemoglobin levels.
However, these symptoms alone are not a definitive indication for blood transfusion.
Other factors, such as the patient's overall clinical condition and the cause of the low hemoglobin, need to be considered.
Choice B rationale:
"My hemoglobin is 7 g/dL, so I need a transfusion." Rationale: This statement indicates that the patient is aware of their low hemoglobin level and believes they need a transfusion.
The hemoglobin level of 7 g/dL is a common threshold used as an indication for blood transfusion, especially in symptomatic patients.
This choice is correct because it aligns with the appropriate clinical indication for a transfusion based on the hemoglobin level.
Choice C rationale:
"I had orthopedic surgery yesterday." Rationale: While surgery can lead to blood loss, the statement alone does not provide sufficient information to determine if a transfusion is necessary.
The decision to transfuse blood should be based on the patient's hemoglobin level, overall clinical condition, and the extent of blood loss during surgery.
Choice D rationale:
"I have a stable cardiovascular disease." Rationale: The presence of stable cardiovascular disease is not directly related to the need for a blood transfusion based on a hemoglobin level of 7 g/dL.
The decision to transfuse should primarily be based on the patient's hemoglobin level and symptoms.
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