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Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply

Hang a bag of 0.9% normal saline with 5% dextrose at the bedside (D5%NS)

Verify the client's name and blood type with a second nurse

Infuse the unit of blood within 4 hours.

Obtain baseline vital signs prior to starting the transfusion

Continuously monitor the client during the first 15 minutes of the transfusion

Insert an 18-gauge intravenous catheter

Insert a 22-gauge intravenous catheter

Answer and Explanation

Correct Answer : B,C,D,E,F

A. Hanging a bag of 0.9% normal saline with 5% dextrose (D5%NS) is incorrect; only normal saline (0.9% NS) should be used to prime the blood transfusion line to avoid hemolysis.

B. Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions and ensure the correct blood product is given.

C. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth in the blood product.

D. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition and monitor for any changes during the transfusion.

E. Continuously monitoring the client during the first 15 minutes of the transfusion is vital for detecting any signs of a transfusion reaction promptly.

F. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions as it provides a sufficient lumen to accommodate the blood flow.

G. Inserting a 22-gauge intravenous catheter is acceptable for some transfusions, but an 18-gauge is preferred for larger blood products.

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Correct Answer is B

Explanation

A. Distended jugular veins may indicate fluid overload or congestive heart failure, not an allergic reaction.

B. Generalized urticaria, or hives, is a classic sign of an allergic transfusion reaction, presenting as an itchy rash or welts on the skin.

C. Bilateral flank pain is more indicative of a hemolytic reaction, particularly due to kidney involvement, rather than an allergic reaction.

D. A blood pressure of 184/92 mm Hg may suggest hypertension or a reaction, but it is not specific to allergic transfusion reactions, which are characterized by skin symptoms like urticaria.

A. Milk and cheese B. Whole grain breads C. Fresh fruits D. Red meat and organ meat

Correct Answer is D

Explanation

A. Milk and cheese are low in iron content and are not recommended for increasing iron levels in clients with iron-deficiency anemia.

B. Whole grain breads may contain some iron but are not as high in iron as other food sources.

C. Fresh fruits do not provide significant amounts of iron and are not a good source for addressing iron deficiency.

D. Red meat and organ meat are excellent sources of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant sources, making them the best choice for increasing iron intake in clients with iron-deficiency anemia.

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Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

Correct Answer is B

Explanation

A nurse is caring for a client with iron-deficiency anemia. When teaching the client about nutrition, the nurse should educate the client which of the following foods contains the most amount of iron?

Correct Answer is D

Explanation

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