You are planning on transfusing a unit of blood. Which of the following are appropriate measures to take? (Select all that apply)
Ensure that patients with AB+ blood type only receive blood from AB type donors
Finish transfusing PRBC's within 2 hours
Remain with the patient during the first 15 minutes of the infusion
Double check the blood product against the patient blood band with another RN
Prime blood tubing with normal saline (NS)
Correct Answer : B,C,D,E
A. Individuals with AB+ blood type can receive blood from any donor type (A, B, AB, or O) because they have no antibodies against A or B antigens. The safest practice is to provide the most compatible blood type, but AB+ recipients are considered universal recipients.
B. To minimize the risk of bacterial growth and transfusion reactions, packed red blood cells (PRBCs) should be transfused within 2 hours of starting the infusion. It’s important to monitor the patient closely during this time.
C. The first 15 minutes of a blood transfusion are critical for observing any immediate adverse reactions. The nurse should stay with the patient during this time to monitor vital signs and assess for any signs of a transfusion reaction.
D. A crucial safety step is to verify the blood product against the patient’s blood band with another registered nurse (RN). This helps prevent errors related to mismatched blood transfusions, which can be life-threatening.
E. Blood transfusion tubing should be primed with normal saline to ensure that the blood product flows properly and to maintain patency. Normal saline is used because it is compatible with blood products and does not cause hemolysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While monitoring drug levels is important, sending a trough level before the initial dose is not standard practice. Trough levels are typically checked just before the next dose of a medication is given, especially for antibiotics like Gentamicin that require monitoring for potential toxicity. Therefore, this option is not the best immediate action.
B. While managing the environment and ensuring patient privacy is important, this option does not address any immediate medical needs related to starting the antibiotic infusion.
C. Educating the patient about potential side effects is essential for informed consent and patient safety. However, while important, this is not the most critical action to take prior to the infusion.
D. Before starting an antibiotic treatment, it is crucial to send a culture and sensitivity test to identify the specific pathogen causing the infection. This ensures that the selected antibiotic (Gentamicin) is appropriate for the identified bacteria, which is vital for effective treatment and to avoid antibiotic resistance.
Correct Answer is C
Explanation
A. Proper wound care is essential in preventing infections, particularly in older adults who may have thinner skin and slower healing processes. However, while this is important, it is just one aspect of a comprehensive infection prevention strategy and does not address broader systemic issues.
B. Older adults are often at higher risk for infections due to waning immunity. Regular vaccinations, such as the flu vaccine, pneumococcal vaccine, and others, can significantly reduce the risk of serious infections. This action is critical but is part of a preventive framework rather than a standalone solution.
C. Hand hygiene is one of the most effective measures to prevent the transmission of infections. Educating clients about proper handwashing techniques and when to wash their hands can significantly reduce the risk of infections, especially in older adults who may be more susceptible due to age-related immune changes.
D. Nutrition plays a vital role in maintaining overall health and supporting the immune system. A well- balanced diet can help older adults fight infections more effectively. However, while important, diet alone may not be as immediately impactful in preventing infections as other measures like hand hygiene and vaccination.
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