(Select all that apply): A nurse is preparing to administer a blood transfusion.
What are the nursing responsibilities before initiating the transfusion? Select three options.
Verify the patient's identification.
Obtain informed consent.
Monitor vital signs during the transfusion.
Prepare the patient for an exchange transfusion.
Document the procedure accurately.
Correct Answer : A,B,E
Choice A rationale:
Verify the patient's identification.
Rationale: Ensuring the correct patient is receiving the blood transfusion is a critical safety step.
Verifying the patient's identification helps prevent transfusion errors and ensures that the right blood product is administered to the right patient.
Choice B rationale:
Obtain informed consent.
Rationale: Obtaining informed consent is a necessary step before any medical procedure, including blood transfusions.
It ensures that the patient understands the risks, benefits, and alternatives to the transfusion and has the opportunity to ask questions and make an informed decision.
Choice E rationale:
Document the procedure accurately.
Rationale: Accurate documentation is essential for maintaining a complete record of the transfusion process.
It includes documenting the patient's identification, vital signs, the type and volume of blood product administered, any adverse reactions, and the patient's response to the transfusion.
This documentation serves as a legal and clinical record of the procedure.
Choice C rationale:
Monitor vital signs during the transfusion.
Rationale: While monitoring vital signs is important during a blood transfusion, it is not a responsibility before initiating the transfusion.
Vital sign monitoring occurs during the transfusion to detect any immediate adverse reactions or transfusion-related complications.
Choice D rationale:
Prepare the patient for an exchange transfusion.
Rationale: Preparing a patient for an exchange transfusion is not a nursing responsibility before initiating a routine blood transfusion.
Exchange transfusions are typically used for specific medical conditions, such as hemolytic disease of the newborn or sickle cell disease, and involve the removal and replacement of a large volume of blood.
Standard blood transfusions do not require this preparation.
For , fresh frozen plasma (FFP) is the most suitable blood product for increasing fibrinogen levels in a patient with hemophilia A.
For , the nursing responsibilities before initiating a blood transfusion include verifying the patient's identification, obtaining informed consent, and documenting the procedure accurately.
Monitoring vital signs is important but occurs during the transfusion, and preparing the patient for an exchange transfusion is not relevant to routine blood transfusions.
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Related Questions
Correct Answer is A
Explanation
"I'll stay with the patient for the entire transfusion."
Choice A rationale:
Staying with the patient for the entire transfusion is a crucial safety measure.
The nurse must monitor the patient for any signs of a transfusion reaction, such as fever, chills, rash, shortness of breath, or changes in vital signs.
Immediate intervention may be required if a reaction occurs.
Choice B rationale:
Adding medications to the blood bag is not within the nurse's scope of practice and should not be done without a specific physician's order.
Medications should be administered separately through a different IV line, if necessary, and only as ordered.
Choice C rationale:
Administering the transfusion at a rate of 4 mL/min is not a standard practice.
The rate of transfusion is determined by the physician's order and the patient's specific needs.
It is not a fixed rate and should be adjusted as needed.
Choice D rationale:
Using any available intravenous line for the transfusion may not be appropriate, especially if the line is already in use for other medications or fluids.
The nurse should select a dedicated line for the transfusion to minimize the risk of contamination or complications.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale:
Normal saline is a sterile solution of sodium chloride in water, and it is a commonly used intravenous fluid to expand blood volume.
It is isotonic, meaning it has a similar osmolarity to blood, and can effectively increase circulating blood volume without adding blood cells.
Choice C rationale:
Albumin is a colloid solution often used as a volume expander.
It contains proteins that help maintain colloid osmotic pressure, which can draw fluid from interstitial spaces into the bloodstream, thereby increasing blood volume and circulation without adding blood cells.
Choice D rationale:
Hydroxyethyl starch (HES) is another colloid solution used as a volume expander.
It works similarly to albumin by increasing colloid osmotic pressure and attracting fluid into the vascular space, thereby increasing blood volume and circulation without adding blood cells.
Choice B rationale:
Erythropoietin (EPO) is a hormone that stimulates the production of red blood cells in the bone marrow.
It does not directly increase blood volume or circulation; instead, it increases the number of red blood cells, which can improve oxygen-carrying capacity in the long term but does not serve as a volume expander.
Choice E rationale:
Oxygen therapy is not a volume expander.
While it can increase the oxygen-carrying capacity of the blood by providing supplemental oxygen, it does not increase blood volume or circulation and is not used for that purpose.
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