A nurse is caring for a client who has a prescription for one unit of packed RBCs. The nurse should plan to remain in the room with the client at which of the following times during the infusion to observe for a transfusion reaction?
The first 2 min
The final 2 min
The final 15 min
The first 15 min
The Correct Answer is D
A. The first 2 min - This is too short a period to monitor effectively for transfusion reactions.
B. The final 2 min - Transfusion reactions are more likely to occur at the beginning of the transfusion rather than at the end.
C. The final 15 min - While it’s still important to monitor, reactions are most likely to be detected earlier in the infusion.
D. The first 15 min - Transfusion reactions typically occur within the first 15 minutes of starting the blood transfusion. The nurse should remain with the patient during this critical period to monitor for any signs of a reaction, such as fever, chills, rash, or difficulty breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 2 hr after obtaining blood from the blood bank. Blood should be started as soon as possible, ideally within 30 minutes to minimize the risk of bacterial growth. Waiting for 2 hours is not appropriate.
B. When the client states he is ready to start the infusion. The client’s readiness should be considered, but the timing should be based on clinical guidelines and safety protocols, not just the client’s preference.
C. As soon as the nurse can prepare the client and the administration set. Blood products should be infused as soon as possible after preparation to reduce the risk of bacterial contamination and ensure efficacy.
D. When the client has finished eating lunch. The infusion timing should not be delayed for non-essential reasons like meal completion unless the client is experiencing issues that could interfere with the transfusion.
Correct Answer is ["A","C","E"]
Explanation
A. Increased heart rate - Tachycardia can occur as the heart compensates for increased blood volume and the need to maintain effective circulation.
B. Increased hematocrit - Hematocrit usually decreases in fluid overload because the increased plasma volume dilutes the red blood cells.
C. Increased blood pressure - Excess fluid volume often leads to hypertension as there is more fluid for the heart to pump, increasing vascular resistance.
D. Increased temperature - Temperature is not directly affected by fluid overload; fever or changes in temperature are more likely related to infection or other inflammatory responses.
E. Increased respiratory rate - Fluid overload can cause pulmonary congestion and decreased oxygenation, leading to increased respiratory effort to maintain adequate oxygen levels.
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