Which nursing action is most important in prevention of transfusion reactions?

Staying with the client during the first 15 minutes of the transfusion.

Properly identifying the client

Warming the blood during administration

Administering the blood at a rate of no more than 2 mL/minute

Answer and Explanation

The Correct Answer is B

A. Staying with the client during the first 15 minutes of the transfusion: Close monitoring during the initial phase allows the nurse to detect early signs of a reaction, such as fever, chills, or hypotension. While essential for safety, this action does not prevent a reaction from occurring; it only facilitates rapid recognition and intervention.

B. Properly identifying the client: Accurate client identification is the most critical step in preventing transfusion reactions because it ensures that the correct blood product is given to the intended recipient. Mismatched blood can cause life-threatening hemolytic reactions, making verification of identity and blood type a primary preventive measure.

C. Warming the blood during administration: Warming blood is sometimes indicated to prevent hypothermia in clients receiving large or rapid transfusions, but it does not prevent immunologic transfusion reactions. This action addresses thermal safety rather than compatibility-related complications.

D. Administering the blood at a rate of no more than 2 mL/minute: Administering blood slowly at the start of a transfusion allows early detection of adverse reactions, but it does not prevent the reaction itself. Rate control is a monitoring strategy rather than a preventive action against mismatched or incompatible transfusions.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Notify the client's health care provider: Contacting the provider will be necessary, but the nurse must first verify the potassium level because the ECG changes—widened QRS and peaked T waves—strongly suggest life-threatening hyperkalemia. Having the value ready allows immediate, precise communication and intervention.

B. Look at the client's current blood urea nitrogen (BUN) and creatinine levels: These levels confirm AKI severity but do not directly explain the dangerous conduction changes. Hyperkalemia poses an immediate risk of cardiac arrest, so potassium assessment takes priority for rapid correction.

C. Document the QRS interval: Documentation is routine but not urgent when ECG changes indicate an unstable electrolyte imbalance. Delaying assessment of potassium prolongs exposure to a potentially fatal arrhythmia and does not address the underlying cause.

D. Check the chart for the most recent blood potassium level: Peaked T waves and a widened QRS are hallmark findings of severe hyperkalemia. Verifying the potassium level is the most immediate step because it confirms the cause and guides emergent therapy such as calcium gluconate, insulin, or dialysis.

A. The arterial line shows a blood pressure of 108/60. B. The pulmonary artery wedge pressure (PAWP) is increased. C. the cardiac output drops from 5 to 3. D. The pulmonary artery pressure (PAP) is decreased.

Correct Answer is C

Explanation

A. The arterial line shows a blood pressure of 108/60: This blood pressure is within an acceptable range and does not immediately indicate the need to adjust ventilator settings. Hemodynamic monitoring must consider overall trends, not a single reading within normal limits.

B. The pulmonary artery wedge pressure (PAWP) is increased: An elevated PAWP indicates increased left ventricular preload or fluid overload, which may require fluid management but does not directly necessitate changing PEEP unless it is contributing to cardiac compromise.

C. The cardiac output drops from 5 to 3: A significant decrease in cardiac output indicates that the high PEEP may be impeding venous return and reducing stroke volume. This is a critical sign that ventilator settings may need adjustment to prevent hemodynamic compromise while maintaining adequate oxygenation.

D. The pulmonary artery pressure (PAP) is decreased: A decrease in PAP is generally not concerning in isolation and may reflect effective oxygenation or reduced pulmonary vascular resistance. It does not typically signal the need to change ventilator settings.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which nursing action is most important in prevention of transfusion reactions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After noting QRS interval has lengthened from 0.08 to 0.16 and T wave is peaked in a client with acute kidney injury (AKI) which action should the nurse take first?

Correct Answer is D

Explanation

A client with respiratory failure has hemodynamic monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 10 cm H2O. Which information indicates that a change in the ventilator settings may be required?

Correct Answer is C

Explanation

A client sustained a crush injury to the chest and is diagnosed with a flail chest. On assessment the nurse should expect to observe

Your septic client is becoming restless and tachypneic. His arterial blood gases show pH 7.50; PaCO2 30 mmHg; HCO3 24 mEq/L; PaO2 76 mmHg; SaO2 90%. You would interpret these ABG findings as consistent with

The client has very thick secretions, making suctioning difficult. The most effective way to thin the secretions for a client with an endotracheal tube in place is by

What is the best rationale for the following health care provider prescriptions for a client with a head injury: elevate the HOB: keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?

The nurse is caring for a client with severe left ventricular dysfunction who has been identified as being at risk for sudden cardiac death. What medical intervention can be performed that may extend the survival of the client?

A client is admitted to the emergency department (ED) and diagnosed as having an ST-segment-elevation myocardial infarction (STEMI). Which question should the nurse ask to determine whether the client is a candidate for fibrinolytic therapy?

As the nurse caring for a ventilator-dependent client who is receiving vecuronium bromide, you assess the level of neuromuscular blockade using "Train-of Four" (TOF) peripheral nerve stimulation. When would you know you have the correct amount of the paralytic being delivered?

The clinic nurse caring for a client with Parkinson disease notes that the client has been taking levodopa and carbidopa for 7 years. For what common side effect should the nurse assess this client?