A nurse is preparing to administer a blood transfusion to a patient.
What should the nurse consider when selecting an intravenous site for the transfusion?
"I'll choose a site with infiltration or phlebitis.”
"I'll use the same IV line for other medications.”
"I'll avoid using sites with edema or infection.”
"I'll use a 24-gauge IV catheter for the transfusion.”
The Correct Answer is C
Choice A rationale:
Choosing a site with infiltration or phlebitis is not appropriate for a blood transfusion.
Infiltration can lead to the transfused blood leaking into the surrounding tissues, and phlebitis can cause discomfort and complications.
A suitable site should be chosen for the transfusion.
Choice B rationale:
Using the same IV line for other medications without flushing it between medications can lead to drug interactions or contamination.
It is generally not recommended to mix blood transfusions with other medications in the same line.
Choice C rationale:
Avoiding sites with edema or infection is a crucial consideration when selecting an intravenous site for a blood transfusion.
Using a site with edema can make it difficult to insert the catheter, and using a site with infection can introduce pathogens into the bloodstream.
Choice D rationale:
Using a 24-gauge IV catheter for a blood transfusion may not be suitable for all patients.
The size of the catheter should be appropriate for the type of blood product being transfused and the patient's vein size.
A larger catheter may be necessary for blood products with higher viscosity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
Choice A rationale:
Transfusion-associated circulatory overload (TACO) is not caused by antibodies in the donor's plasma.
It is primarily a result of excessive volume administered during a transfusion.
Choice B rationale:
Transfusion-related acute lung injury (TRALI) is indeed a leading cause of transfusion-related mortality.
TRALI is characterized by acute respiratory distress and is caused by antibodies in the donor's plasma that react with leukocytes in the recipient's lungs.
Choice C rationale:
Febrile nonhemolytic reaction is not the most common type of transfusion reaction.
It is relatively common but not the most common.
Other reactions, like allergic reactions or acute hemolytic reactions, can also occur.
Choice D rationale:
Allergic reactions are not typically caused by ABO incompatibility between the donor and recipient blood.
ABO incompatibility is more likely to lead to acute hemolytic reactions.
Allergic reactions are usually triggered by sensitivities to plasma proteins or allergens in the blood product.
Choice E rationale:
Bacterial contamination of blood products can indeed result in sepsis.
This is a severe and life-threatening complication of transfusion, making it important to ensure the safety of blood products and proper handling to prevent contamination.
Correct Answer is A
Explanation
Choice A rationale:
Delayed hemolytic reactions occur several days after a blood transfusion and are characterized by symptoms like fever, jaundice, hemoglobinuria, and a positive Coombs test.
This matches the patient's presentation described in the question.
Choice B rationale:
Transfusion-associated graft-versus-host disease (TA-GVHD) typically presents with fever, rash, diarrhea, and liver dysfunction.
It is a rare but severe complication that occurs when the donor's lymphocytes attack the recipient's tissues.
Choice C rationale:
Post-transfusion purpura is a rare condition characterized by severe thrombocytopenia (low platelet count) that occurs a week or more after a blood transfusion.
It does not match the symptoms described in the question.
Choice D rationale:
Transfusion-related immunomodulation (TRIM) is a theoretical concept and not a recognized clinical entity.
It is not associated with the specific symptoms mentioned in the question.
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