A nurse is assessing a client's history before a blood transfusion. Which condition should the nurse identify as a contraindication for transfusion?

Iron-deficiency anemia

Chronic kidney disease

Hemolytic anemia

Hypertension

Answer and Explanation

The Correct Answer is C

A) Incorrect: Iron-deficiency anemia is not a contraindication for a blood transfusion. In fact, it is one of the common indications for transfusion in clients with severe anemia.

B) Incorrect: Chronic kidney disease is not a contraindication for a blood transfusion. Transfusions may be necessary for clients with chronic kidney disease who develop anemia due to decreased erythropoietin production.

C) Correct: Hemolytic anemia is a contraindication for a blood transfusion. This condition involves the destruction of red blood cells, and a transfusion with incompatible blood can worsen the hemolysis and lead to a severe transfusion reaction.

D) Incorrect: Hypertension is not a contraindication for a blood transfusion. While the nurse should monitor blood pressure during the transfusion, hypertension alone does not preclude the need for a transfusion in a client with other indications for blood products.

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Correct Answer is B

Explanation

A) Incorrect: Administering the blood transfusion when agglutination and incompatibility are detected is unsafe and may lead to severe transfusion reactions. The nurse should not proceed with the transfusion.

B) Correct: In the presence of agglutination and incompatibility between the donor's red blood cells and the client's plasma, the nurse must discontinue the blood transfusion immediately and return the blood to the blood bank. This ensures the client's safety and prevents further adverse reactions.

C) Incorrect: Increasing the infusion rate will not resolve the incompatibility issue and may worsen the client's condition. The nurse should stop the transfusion promptly.

D) Incorrect: Mixing the incompatible blood with normal saline will not resolve the incompatibility issue and is not a safe practice. The nurse should not proceed with the transfusion and should return the blood to the blood bank.

A. Client reports mild headache. B. Client has slightly elevated temperature. C. Client's skin appears pale and cool to touch. D. Client experiences generalized muscle weakness.

Correct Answer is B

Explanation

A) Incorrect: A mild headache is a common and expected side effect of a blood transfusion and may not require immediate reporting to the healthcare provider.

B) Correct: A slightly elevated temperature in a client who received a blood transfusion 2 hours ago could indicate a delayed transfusion reaction. The nurse should report this finding to the healthcare provider for further evaluation.

C) Incorrect: Pale and cool skin may be an expected finding in a client who received a blood transfusion, especially if they experienced a rapid transfusion or had a reaction. However, it is not the priority finding to report.

D) Incorrect: Generalized muscle weakness may occur for various reasons and may not be directly related to a delayed transfusion reaction. The nurse should prioritize reporting the slightly elevated temperature.

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A nurse is assessing a client's history before a blood transfusion. Which condition should the nurse identify as a contraindication for transfusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?

Correct Answer is B

Explanation

A client received a blood transfusion 2 hours ago. The nurse is assessing for signs of a delayed transfusion reaction. Which assessment finding should the nurse report to the healthcare provider?

Correct Answer is B

Explanation

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