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. Stop the infusion of blood. The client’s symptoms suggest a possible acute hemolytic transfusion reaction, which is a life-threatening emergency. The first and most critical action is to stop the blood transfusion immediately to prevent further reaction and additional hemolysis.
B. Inform the provider: This is an important action but should be done after stopping the transfusion to prevent further complications.
C. Obtain a urine specimen: This is done to check for hemoglobinuria, but it is not the immediate priority.
D. Notify the laboratory: This is part of the follow-up procedure but should be done after stopping the transfusion and stabilizing the patient.
Correct Answer is C
Explanation
A. Packed RBCs - These are used to treat anemia or significant blood loss but do not address the clotting deficiency in hemophilia.
B. Fresh frozen plasma - This contains all clotting factors, but in hemophilia A, specifically replacing factor VIII is more effective and targeted.
C. Recombinant - Recombinant factor VIII is a synthetic form of the clotting factor that patients with hemophilia A are deficient in. It is used to increase factor VIII levels before procedures to prevent excessive bleeding.
D. Prophylactic antibiotics - These are used to prevent infection but do not help in managing the bleeding risks associated with hemophilia.
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