Which of the following would not be an appropriate nursing intervention when preparing to administer a blood transfusion?

Having 2 RNs ensure the blood product is properly labeled and matches the client’s identification

Ensuring that the client signed a consent form for receiving blood transfusions beforehand

Preparing a primary and secondary IV tubing

Obtaining a bag of 0.9% sodium chloride

Answer and Explanation

The Correct Answer is C

A) Having 2 RNs ensure the blood product is properly labeled and matches the client’s identification:
Two registered nurses must independently verify that the blood product matches the patient's identification and that it is properly labeled. This is a critical safety measure to prevent errors, such as mismatched blood transfusions, which can lead to severe complications like hemolytic reactions. Proper verification before administration is a standard safety protocol in blood transfusion procedures.

B) Ensuring that the client signed a consent form for receiving blood transfusions beforehand:
Obtaining informed consent is a vital legal and ethical step before administering a blood transfusion. The nurse must ensure that the patient understands the potential risks and benefits of the procedure and has signed a consent form prior to transfusion. Without consent, the transfusion cannot legally be performed. This is a key part of patient rights and nursing responsibilities.

C) Preparing a primary and secondary IV tubing:
For blood transfusions, only blood administration tubing should be used, which typically includes a filter to prevent the infusion of any debris or clots. Using regular IV tubing (primary and secondary) for blood administration is not recommended, as it may not have the necessary filter and could potentially introduce contaminants. Blood should always be administered with tubing specifically designed for that purpose.

D) Obtaining a bag of 0.9% sodium chloride:
Normal saline is typically used as the solution to flush the IV line before and after the transfusion. It is compatible with blood products and helps to prevent clotting or reactions in the line. This is an essential step to ensure safe and effective blood administration.

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Correct Answer is A

Explanation

A) Obtain samples for urine culture and urinalysis:
This is the first priority. The symptoms described—urinary frequency, dysuria (painful urination), and fever—are suggestive of a urinary tract infection (UTI). To confirm the diagnosis and identify the causative organism, it is critical to obtain a urine sample for both a urinalysis and urine culture. The culture will help guide antibiotic therapy once the organism is identified. This is the foundational step before initiating any treatment. The results will also help determine whether the infection is localized or more severe, like a pyelonephritis
or systemic infection.

B) Insert a Foley catheter:
Inserting a Foley catheter may be necessary if the patient is unable to void, but it is not the first intervention in this case. A Foley catheter is generally used for urinary retention or if monitoring of urine output is necessary. In the context of suspected UTI symptoms, a Foley catheter should only be inserted if there is a clear need, not just for the convenience of obtaining a sample. Additionally, inserting a Foley catheter could introduce bacteria if the patient is not already catheterized and should therefore be avoided unless medically indicated.

C) Begin broad-spectrum IV antibiotics:
While starting antibiotics is important in treating a suspected UTI, especially in the presence of fever and potential infection, obtaining a urine sample for culture and urinalysis should be done first. This allows the healthcare team to tailor antibiotic therapy based on the culture results, reducing the risk of unnecessary or incorrect antibiotic use. If the patient is febrile and appears severely ill, broad-spectrum antibiotics may be started after obtaining the urine sample, but the culture and urinalysis must still be prioritized.

D) Prepare the client for a CT scan:
While imaging studies like a CT scan may be helpful in evaluating for complications, they are not the first step in managing the patient’s symptoms. Obtaining the urine sample and identifying whether an infection is present is essential for guiding further management. A CT scan may be ordered later if the clinical suspicion for complications remains high after the initial evaluation and lab results.

A. 15-30g oral carbohydrates. B. 10% dextrose continuous IV infusion C. Glucagon PO, D. 50% dextrose in water (050W) IV push

Correct Answer is D

Explanation

A. 15-30g oral carbohydrates:
Oral carbohydrates are a first-line treatment for hypoglycemia in a conscious, alert patient who can safely swallow. However, since the patient is unresponsive, administering oral carbohydrates is not an appropriate option. The patient’s inability to swallow safely increases the risk of aspiration, making IV treatment the priority in this case.

B. 10% dextrose continuous IV infusion:
A 10% dextrose IV infusion can be used in the management of hypoglycemia, but in an acute, emergency setting where the patient is unresponsive and their blood glucose is critically low (30 mg/dL), a rapid-acting intervention is needed. A bolus dose of a concentrated solution, such as 50% dextrose, is more appropriate for quickly raising the blood glucose level in this situation, rather than a continuous infusion, which takes longer to achieve an effective increase in glucose.

C. Glucagon PO:
Glucagon is typically used for hypoglycemia in patients who are unconscious or unable to take oral glucose. However, glucagon is typically administered intramuscularly (IM) or subcutaneously (SQ), not orally (PO). Administering glucagon orally is ineffective, as it would not be absorbed by the body in the necessary manner to correct hypoglycemia. Therefore, this option is inappropriate.

D. 50% dextrose in water (50% DW) IV push:
When a patient is unresponsive and their blood glucose level is critically low (30 mg/dL), the priority treatment is an immediate, concentrated source of glucose. Administering 50% dextrose IV push is the most appropriate intervention in this scenario. It provides a rapid and effective increase in blood glucose levels, which is critical for reversing hypoglycemia in an emergency situation. This is the fastest and most direct approach to treating severe hypoglycemia in an unresponsive patient.

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Which of the following would not be an appropriate nursing intervention when preparing to administer a blood transfusion?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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