A charge nurse is supervising a newly licensed nurse care for a client who is receiving a transfusion of packed RBC. The nurse suspects a possible hemolytic reaction. After stopping the blood transfusion, which of the following actions by the new nurse requires intervention by the charge nurse?
The nurse collects a urine specimen.
The nurse starts the transfusion of another unit of blood product.
The nurse initiates an infusion of 0.9% sodium chloride.
The nurse sends a blood specimen to the laboratory.
The Correct Answer is B
A. Collect urine specimen
Appropriate to assess for hemoglobinuria during a hemolytic reaction.
B. Starts another unit of blood
Incorrect action—transfusion must be stopped and not restarted without provider evaluation.
C. Initiates 0.9% sodium chloride infusion
Maintains vascular access and supports renal perfusion-appropriate.
D. Sends blood specimen
Required for follow-up testing and identification of reaction cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Adolescent with sickle cell pain (7/10)
Needs prompt treatment, but not as life-threatening as airway obstruction.
B. Toddler with asthma and SpO₂ 95% on 2L O₂
Stable oxygenation; not an immediate emergency.
C. Toddler with otitis media and fever
Infection is concerning but not life-threatening.
D. Child with acute epiglottitis, drooling, no cough
These are classic signs of airway obstruction. Airway management is the priority—this is life-threatening.
Correct Answer is D
Explanation
A. Preventing musculoskeletal disability
Important, but not priority in life-threatening trauma.
B. Stabilizing cardiac arrhythmias
Secondary-ABCs take precedence.
C. Decreasing intracranial pressure
Important in head injury but only after airway is secure.
D. Airway protection
Airway is the priority in trauma (per ABCs: Airway, Breathing, Circulation).
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