(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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Oxygen therapy can improve oxygen-carrying capacity but does not directly address chronic anemia due to kidney disease.
Erythropoietin therapy is a more targeted option.
Choice B rationale:
Erythropoietin injections stimulate red blood cell production and can be effective in treating anemia associated with chronic kidney disease.
It is a suitable alternative to blood transfusion in this context.
Choice C rationale:
Volume expanders like lactated Ringer's primarily increase blood volume and circulation but do not address anemia or increase hemoglobin levels.
This option may not be the most appropriate for the client's condition.
Choice D rationale:
Iron therapy is generally used to treat iron deficiency anemia, but it may not be the most effective option for anemia related to chronic kidney disease, as it does not address the underlying cause.
Erythropoietin therapy is a more targeted approach.
Correct Answer is A
Explanation
Choice A rationale:
Whole blood.
Rationale: Whole blood contains all blood components, including red blood cells, plasma, platelets, and clotting factors.
It is used for patients with symptomatic anemia and ongoing bleeding, as it can address both the anemia and provide clotting factors to assist in hemostasis.
Choice B rationale:
Packed red blood cells (PRBCs)
Rationale: Packed red blood cells are primarily used to increase the oxygen-carrying capacity in patients with anemia or significant blood loss.
While they can address the anemia component of the patient's condition, they do not provide clotting factors.
Therefore, they may not be the best choice for patients with ongoing bleeding.
Choice C rationale:
Fresh frozen plasma (FFP)
Rationale: Fresh frozen plasma is rich in clotting factors and is used to treat bleeding disorders or clotting factor deficiencies.
It can be beneficial for patients with bleeding issues but does not address the anemia component of the patient's condition.
Choice D rationale:
Platelets.
Rationale: Platelets are responsible for clot formation and are primarily used to treat thrombocytopenia or clotting disorders.
They do not address the anemia component of the patient's condition and are not typically considered an alternative to blood transfusion for anemic patients with ongoing bleeding.
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