The nurse is monitoring a patient who is receiving a blood transfusion. The nurse identifies that the blood transfusion started over four hours ago. What intervention will the nurse implement next?

Increase the rate of the transfusion to complete it as quickly as possible.

Stop the transfusion immediately and document the amount infused.

Continue the transfusion and monitor vital signs every 15 minutes.

Continue the transfusion at the current rate until it is completed.

Answer and Explanation

The Correct Answer is B

Choice A reason: Increasing the rate of the transfusion to complete it as quickly as possible is not safe. Blood transfusions should be completed within four hours to prevent complications such as bacterial contamination and hemolysis.

Choice B reason: Stopping the transfusion immediately and documenting the amount infused is the appropriate intervention. Blood products that have been transfusing for more than four hours must be stopped to ensure patient safety and prevent adverse reactions. Documentation ensures that the healthcare team is aware of the situation and can take appropriate follow-up actions.

Choice C reason: Continuing the transfusion and monitoring vital signs every 15 minutes is not appropriate after the four-hour window has passed. The risk of complications increases with prolonged transfusion times.

Choice D reason: Continuing the transfusion at the current rate until it is completed is not safe. The transfusion must be stopped after four hours to prevent potential complications.

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Correct Answer is B

Explanation

Choice A reason: Notifying the blood bank of the suspected transfusion reaction is important, but maintaining the IV access with normal saline infusion takes priority to ensure that the patient remains stable and to prevent any further complications.

Choice B reason: Maintaining IV access with normal saline infusion is the first priority. This action helps to keep the vein open, provide fluids, and flush out any remaining blood product from the IV line, reducing the risk of further reaction.

Choice C reason: Facilitating the transfer of the patient to the critical care unit may be necessary if the patient's condition worsens, but it is not the immediate first step.

Choice D reason: Rechecking identification labels and numbers is important to confirm the correct blood product was given, but it comes after ensuring the patient’s stability by maintaining IV access with saline.

A. Check the patient's blood pressure before and after the IV administration. B. Ensure the dialysis access site is used for IV administration when possible. C. Verify the correct fluid type and rate as per the physician's order. D. Monitor for signs of infiltration or extravasation at the IV site.

Correct Answer is C

Explanation

Choice A reason: Checking the patient's blood pressure before and after IV administration is important, but it is not the most critical action to ensure safety during the procedure.

Choice B reason: Ensuring the dialysis access site is used for IV administration when possible is not standard practice. The dialysis access site is typically reserved for dialysis treatments to prevent complications.

Choice C reason: Verifying the correct fluid type and rate as per the physician's order is the most important action. Ensuring the right fluid type and rate prevents potential complications such as fluid overload, electrolyte imbalances, and adverse reactions.

Choice D reason: Monitoring for signs of infiltration or extravasation at the IV site is important, but verifying the correct fluid type and rate takes precedence to prevent any errors in the initial setup.

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The nurse is monitoring a patient who is receiving a blood transfusion. The nurse identifies that the blood transfusion started over four hours ago. What intervention will the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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