Order the steps for completing a blood transfusion.
Ensure MDHCP has discussed risks and benefits of blood transfusion.
Obtain cross match and send it to blood bank.
Initiate transfusion through a large gauge IV per hospital protocol.
Educate patient on signs and symptoms of transfusion reaction.
Gain blood from bank, confirm correct patient, correct product, correct cross match with 2 RNs.
Continue to monitor patient for transfusion reaction for 24 hours following transfusion.
The Correct Answer is A,D,B,E,C,F,G,H,I
- Ensure MDHCP has discussed risks and benefits of blood transfusion. (a)
- Educate patient on signs and symptoms of transfusion reaction. (d)
- Obtain cross match and send it to blood bank. (b)
- Gain blood from bank, confirm correct patient, correct product, correct cross match with 2 RNs. (e)
- Initiate transfusion through a large gauge IV per hospital protocol. (c)
- Start transfusion slowly for the first 15 minutes and stay with patient for the first 15 minutes. (f)
- Increase rate of transfusion and monitor patient frequently. (g)
- Ensure transfusion is complete within 4 hours of starting. (h)
- Continue to monitor patient for transfusion reaction for 24 hours following transfusion. (i)
Rationale:
- Ensure MDHCP has discussed risks and benefits of blood transfusion: It's essential that the healthcare provider discusses with the patient the potential risks and benefits of receiving a blood transfusion. This step is crucial for informed consent.
- Educate patient on signs and symptoms of transfusion reaction: Before starting the transfusion, the patient should be educated on what signs and symptoms to watch out for that might indicate an adverse reaction, such as fever, chills, hives, or shortness of breath.
- Obtain cross match and send it to blood bank: A blood sample is taken from the patient to determine their blood type and to perform a crossmatch, which ensures that the donor blood is compatible with the patient's blood.
- Gain blood from bank, confirm correct patient, correct product, correct cross match with 2 RNs: Once the blood is ready, two registered nurses (RNs) will verify the patient's identity, the blood product, and the crossmatch results to ensure everything is correct before proceeding.
- Initiate transfusion through a large gauge IV per hospital protocol: The blood transfusion is started using a large gauge intravenous (IV) line, as per hospital protocols to ensure proper flow and reduce complications.
- Start transfusion slowly for the first 15 minutes and stay with patient for the first 15 minutes: The transfusion is started at a slow rate to monitor for any immediate adverse reactions. The healthcare provider stays with the patient during this time to closely observe them.
- Increase rate of transfusion and monitor patient frequently: If no adverse reactions are noted in the first 15 minutes, the rate of transfusion can be increased. The patient is monitored frequently throughout the transfusion for any signs of a reaction.
- Ensure transfusion is complete within 4 hours of starting: Blood products should be transfused within 4 hours to minimize the risk of bacterial growth and to ensure the effectiveness of the transfusion.
- Continue to monitor patient for transfusion reaction for 24 hours following transfusion: After the transfusion is complete, the patient is monitored for at least 24 hours for any delayed transfusion reactions, such as fever, allergic reactions, or other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E","F"]
Explanation
Choice A reason: Applying a clean, dry dressing over the VTE/DVT site is not necessary. VTE/DVT usually involves deep veins where there are no visible wounds requiring dressings. This instruction is irrelevant to the management and discharge instructions for a patient with DVT on anticoagulant therapy.
Choice B reason: Monitoring activated partial thromboplastin time (aPTT) results is relevant for heparin therapy, not for warfarin. Warfarin therapy is monitored using the international normalized ratio (INR). Therefore, this instruction is not appropriate for a patient being discharged on warfarin.
Choice C reason: Administering the warfarin dose at the same time each day is crucial for maintaining consistent blood levels of the medication, ensuring its effectiveness. It helps to maintain steady anticoagulation and reduces the risk of complications associated with fluctuating blood levels of warfarin.
Choice D reason: Instructing the patient to take aspirin or NSAIDs as needed for pain is inappropriate because these medications can increase the risk of bleeding when taken with warfarin. Patients on warfarin should avoid these medications and use alternatives like acetaminophen (Tylenol) for pain relief.
Choice E reason: Advising the patient to use electric razors, not straight razors, when shaving is important to prevent cuts and bleeding. Warfarin increases the risk of bleeding, and using an electric razor minimizes the chance of nicks and cuts that could lead to significant bleeding.
Choice F reason: Monitoring the level of anticoagulation with warfarin using INR results is essential. Regular INR monitoring ensures that the patient maintains a therapeutic level of anticoagulation and helps prevent both clotting and bleeding complications. Adjustments to the warfarin dose are made based on INR results.
Correct Answer is B
Explanation
Choice A reason:
Receiving a blood transfusion after 1992 does not strongly indicate the need for hepatitis C screening because screening of blood products for hepatitis C became standard practice in the early 1990s. By 2005, the risk of transmission via transfusion had been effectively eliminated. Therefore, while a past transfusion may be part of the patient's health history, it does not necessitate hepatitis C screening in this case.
Choice B reason:
Intravenous drug use, even if it occurred 20 years ago, is a significant risk factor for hepatitis C infection. The virus is commonly transmitted through the sharing of needles or other equipment used to inject drugs. Due to the long latency period of hepatitis C, individuals with a history of IV drug use are at high risk and should be screened regardless of how long ago the exposure occurred. This is the most relevant information in the patient’s history to prompt screening.
Choice C reason:
Frequent dining in fast-food restaurants does not indicate a risk for hepatitis C. Hepatitis C is primarily spread through blood-to-blood contact, not through food or drink. This choice reflects a misunderstanding of the transmission pathways of hepatitis C and is irrelevant to the patient’s screening needs.
Choice D reason:
Traveling to a country with poor sanitation is more associated with the risk of hepatitis A, a virus that is often spread through contaminated water or food. Hepatitis C, however, is not typically transmitted via poor sanitation or contaminated food and water. Screening for hepatitis C would not be warranted based solely on travel history to such countries.
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