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. “I need something for the pain in my eye. I can't stand it." Severe pain after cataract surgery is unusual and could indicate complications such as increased intraocular pressure or infection. This should be reported immediately to the provider for further evaluation.
B. "It’s hard to see with a patch on one eye. I'm afraid of falling": This is a common concern and relates to mobility safety, not a sign of a surgical complication.
C. "My eye really itches, but I'm trying not to rub it.": Itching can be a normal response post-surgery due to healing. Patients should avoid rubbing the eye, and this does not necessarily indicate a complication.
D. "The bright light in this room is really bothering me.": Photophobia or sensitivity to light can be common postoperatively and is usually not a sign of a serious issue.
Correct Answer is B
Explanation
A. Notifying the provider: This is important but should be done after stopping the transfusion.
B. Stopping the transfusion. Chills and back pain during a blood transfusion can indicate a serious transfusion reaction, such as an acute hemolytic reaction. The priority action is to stop the transfusion immediately to prevent further complications
C. Covering the client with a blanket: This addresses the symptom of chills but does not address the potential life-threatening reaction.
D. Assessing the client's skin for a rash: This is part of the assessment for transfusion reactions but is not the priority compared to stopping the transfusion.
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