The nurse is caring for a client with A+ blood who has been prescribed a blood transfusion.
The nurse places a 20-gauge peripheral intravenous (IV) line, flushes it with normal saline, and verifies the client has signed consent.
What is the next step in the transfusion process?
Pick up blood from the blood bank.
Double check the blood with another registered nurse (RN).
Prime the tubing with blood and saline.
Initiate the blood transfusion within one hour of obtaining blood.
The Correct Answer is A
Safe blood administration requires a specific sequence to ensure product viability and patient safety. The nurse must apply institutional protocols regarding the timing of blood retrieval, bedside verification, and transfusion initiation to minimize errors and prevent the waste of blood components.
Choice A rationale
Once the IV is established and consent is obtained, the nurse must retrieve the blood. Blood must be picked up only when the nurse is ready to begin the process, as it must be started quickly after leaving.
Choice B rationale
Double checking the blood with a second registered nurse occurs at the bedside immediately before the transfusion begins. This step follows the retrieval of the blood from the bank and ensures the unit matches the patient and prescription.
Choice C rationale
Priming the Y-tubing with normal saline is necessary, but the nurse cannot prime with blood until the blood has been obtained and verified at the bedside. Normal saline is the only compatible fluid for blood transfusions.
Choice D rationale
While initiation timing is critical, blood must generally be started within 30 minutes of being removed from the blood bank refrigerator, not one hour. This prevents bacterial growth and maintains the integrity of the red cells.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The assessment of postpartum hemorrhage requires differentiating between uterine atony and other sources of bleeding. When the fundus remains firm despite heavy lochia saturation, nurses must apply knowledge of cervical or vaginal lacerations and prioritize immediate medical notification for intervention.
Choice A rationale
Fundal massage is the primary intervention for uterine atony, characterized by a soft or boggy uterus. Since the assessment reveals a firm fundus at the umbilicus, massage is unnecessary and will not address the source of the bleeding.
Choice B rationale
Satiating a pad in 15 minutes is a sign of severe postpartum hemorrhage. A firm fundus suggests the bleeding is likely from a laceration rather than atony. Rapid notification of the provider is essential for surgical repair.
Choice C rationale
Oxytocin is a uterotonic medication used to stimulate uterine contractions and manage hemorrhage caused by atony. Because the fundus is already firm, administering oxytocin is inappropriate and will not resolve bleeding originating from a suspected tissue tear.
Choice D rationale
Assisting the client to the restroom helps empty the bladder, which can resolve a displaced, boggy fundus. However, with a firm fundus and rapid blood loss, this delays critical care and poses a fainting risk for the client.
Correct Answer is D
Explanation
Management of labor induction requires continuous physiological monitoring to ensure maternal and fetal safety. Nurses must apply knowledge of uterine tachysystole and fetal oxygenation to prevent hypoxic injury. Establishing baseline data for uterine activity and fetal heart patterns is the primary prerequisite.
Choice A rationale
Administering large fluid boluses is not standard prior to oxytocin unless anesthesia is imminent. While hydration is important, preventing hypotension is more relevant to regional blocks than to the initiation of synthetic oxytocin for uterine contractions.
Choice B rationale
Patient education is a vital component of informed consent and nursing care. However, in an acute clinical setting, ensuring physiological safety through monitoring takes precedence over documentation of teaching before the medication is physically started.
Choice C rationale
Vertex cephalic presentation is the ideal longitudinal lie for vaginal delivery. Notifying the provider of malposition would be inaccurate as the fetus is correctly positioned. Holding the medication based on this assessment would be clinically inappropriate.
Choice D rationale
Oxytocin carries a high risk for uterine hyperstimulation. Continuous electronic fetal monitoring is essential to establish a baseline fetal heart rate and evaluate contraction frequency, ensuring the fetus tolerates the induced stress of labor contractions.
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