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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Choice A rationale:
Fever is a potential sign of a delayed transfusion reaction.
Delayed transfusion reactions can occur several days after a blood transfusion and may present with fever as a symptom.
This can be indicative of hemolysis or an immune response to the transfused blood.
Choice C rationale:
Jaundice is another sign that the nurse should monitor for delayed transfusion reactions.
Jaundice can be a result of hemolysis, where the red blood cells are destroyed, leading to an increase in bilirubin levels in the bloodstream.
Choice B rationale:
Increased urine output is not typically associated with delayed transfusion reactions.
Delayed reactions are more likely to manifest as fever, jaundice, or other signs of hemolysis.
Choice D rationale:
Hypertension is not a common sign of delayed transfusion reactions.
These reactions are more likely to present with symptoms related to the destruction of red blood cells, such as fever and jaundice.
Choice E rationale:
Decreased oxygen saturation is not a typical sign of delayed transfusion reactions.
It is important to monitor oxygen saturation during a blood transfusion, but this is more relevant to immediate transfusion reactions, such as transfusion-related acute lung injury (TRALI)
Correct Answer is C
Explanation
Choice A rationale:
Transfusion-associated circulatory overload (TACO) is characterized by symptoms related to fluid overload, such as dyspnea and fluid accumulation, but not abdominal symptoms like abdominal pain, nausea, vomiting, and diarrhea.
Choice B rationale:
Transfusion-related acute lung injury (TRALI) primarily presents with respiratory symptoms and is not associated with gastrointestinal symptoms like nausea, vomiting, and diarrhea.
Choice C rationale:
Acute hemolytic reactions occur when there is a mismatch between the donor and recipient blood types, resulting in rapid destruction of transfused red blood cells.
Symptoms include abdominal pain, nausea, vomiting, and diarrhea, which are consistent with the client's presentation described in the question.
Choice D rationale:
Allergic reactions to blood transfusions typically present with symptoms like itching, hives, and flushing, but not with gastrointestinal symptoms like abdominal pain, nausea, vomiting, and diarrhea.
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