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 C

Explanation

A) RBCs 4.3 million/µL:
While a low RBC count can indicate anemia, the specific value provided here is not suggestive of anemia, and it does not explain the patient's symptoms of fatigue, weakness, and dizziness as clearly as a low hemoglobin would.

B) Potassium 4.8 mEq/L:
This result is not concerning and does not directly relate to the patient's reported symptoms of pallor, fatigue, and dizziness. Therefore, this lab result does not take priority in planning care at this time.

C) Hemoglobin of 9 g/dl:
This result is consistent with anemia, which is a likely cause of the patient’s symptoms of fatigue, weakness, dizziness, and pallor. Anemia can lead to decreased oxygen delivery to tissues, explaining the symptoms the patient is experiencing. The priority action for the nurse should be to address the underlying cause of anemia and manage it to improve the patient’s oxygenation and overall condition.

D) Sodium 137 mEq/L:
Although sodium imbalances can cause neurological symptoms such as confusion or lethargy, the patient’s reported symptoms of pallor, fatigue, and dizziness are more likely related to anemia. Sodium is not the most urgent concern for this patient at the moment.

A. NG tube placement B. Low calorie and low protein diet C. Stool softeners and laxatives D. Barium contrast imaging studies

Correct Answer is A

Explanation

A. NG tube placement:
In patients with an exacerbation of inflammatory bowel disease (IBD), particularly in cases of severe flare-ups, the gastrointestinal tract may need rest, and the patient may have difficulty maintaining adequate nutrition. An NG (nasogastric) tube may be used for enteral feeding if the patient is unable to tolerate oral intake, or to provide bowel rest if indicated. Nutritional support via an NG tube can help provide essential nutrients and manage symptoms during an exacerbation, especially if the patient is experiencing severe nausea, vomiting, or malabsorption.

B. Low calorie and low protein diet:
During an IBD flare, the patient typically needs a higher-calorie, higher-protein diet to support healing and immune function. A low-calorie, low-protein diet would not be appropriate, as it would not provide the necessary nutrients for recovery and tissue repair. In fact, nutritional support is often one of the key components in managing IBD exacerbations. A diet rich in calories and protein is often recommended to prevent malnutrition.

C. Stool softeners and laxatives:
Stool softeners and laxatives are generally contraindicated during an IBD flare, as they can exacerbate diarrhea and increase bowel motility, which may worsen symptoms such as abdominal pain, cramping, and diarrhea. The focus during an exacerbation of IBD is typically on controlling inflammation, rest, and reducing bowel irritation, rather than promoting bowel movements.

D. Barium contrast imaging studies:
Barium contrast imaging studies are generally not performed during an acute exacerbation of IBD because they can cause further irritation to the inflamed bowel. Imaging studies are typically used for diagnosis and assessment of disease extent in a stable or chronic phase, rather than during an acute flare. The priority during a flare is managing symptoms and controlling inflammation, not conducting procedures that could aggravate the condition.

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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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