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 A
Explanation
A. "Eating a high fiber diet will reduce my risk for developing skin cancer." There is no evidence that a high-fiber diet specifically reduces the risk of skin cancer. This statement indicates a misunderstanding and a need for further teaching.
B. "I should check my skin monthly for any changes." Regular self-examinations are recommended to detect early signs of skin cancer.
C. "I should use sunscreen even on cloudy days." UV rays can penetrate clouds, so using sunscreen on cloudy days is an important preventive measure.
D. "I should avoid the use of tanning booths." Tanning booths increase the risk of skin cancer, so avoiding them is a correct preventive action.
Correct Answer is D
Explanation
A. Phlebotomist - Phlebotomists are trained in drawing blood and handling specimens but are not typically trained to verify blood products for transfusion.
B. Assistive personnel - Assistive personnel (e.g., nursing assistants) do not have the required training or authority to verify blood products for transfusion.
C. Senior nursing student - Although a senior nursing student may have some clinical experience, they do not have the qualifications or the responsibility required for this critical safety task.
D. Oncology nurse - An oncology nurse is a registered nurse with specialized training and experience in administering blood products and managing the associated risks, making them qualified to double-check blood labels and patient identification.
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