The nurse is performing the safety checks prior to initiating a packed red blood cell transfusion for a patient whose blood type is A positive. The nurse observes the unit is AB negative. What is the nurse's best first action?

Call the blood bark

Initiate the transfusion

Take and record the patients vital signs

Notify the physician

Answer and Explanation

The Correct Answer is A

A. The first action should be to call the blood bank to report the mismatch in blood type. The patient is A positive, and the blood unit is AB negative, which is not compatible and could lead to a serious transfusion reaction. The blood bank can provide the correct unit of blood.
B. Initiating the transfusion with the wrong blood type is dangerous and could cause a life-threatening reaction.
C. Taking and recording vital signs is important but should only occur after confirming the correct blood product. Starting a transfusion with the wrong blood is a safety hazard.
D. While notifying the physician is important, the immediate action is to contact the blood bank to resolve the blood type mismatch.

Nursing Test Bank

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Correct Answer is ["2000"]

Explanation

Answer: 2000

Rationale:

Step 1: Determine the volume remaining
400 mL of IV fluid is left.

Step 2: Determine the infusion rate
80 mL/hour

Step 3: Calculate the time it will take to infuse the remaining fluid:
Time = Volume ÷ Rate
Time = 400 mL ÷ 80 mL/hour = 5 hours

Step 4: Add the infusion time to the current time
Arrival time = 1500
1500 + 5 hours = 2000

Correct Answer is ["480"]

Explanation

Convert time to hours:
25 minutes ÷ 60 = 0.4167 hours

Step 2:
Use the formula:
Rate (mL/hr) = Volume (mL) ÷ Time (hr)

Rate = 200 mL ÷ 0.4167 hr ≈ 480 mL/hr

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The nurse is performing the safety checks prior to initiating a packed red blood cell transfusion for a patient whose blood type is A positive. The nurse observes the unit is AB negative. What is the nurse's best first action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving 1000 mL 0.9% NaCl at 80 mL/hr. On arrival to the unit at 1500, the client has 400 mL of IV fluid remaining. At what time should the nurse expect to hang a new bag? (please use military time)

Correct Answer is ["2000"]

Explanation

A client is ordered to receive a bolus of 200 mL of NSS in 25 minutes. At what rate should the nurse set the IV pump?

Correct Answer is ["480"]

Explanation

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