A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?

Check the client's vital signs from the previous shift prior to the initiation of the transfusion.

Administer the blood via a 21-gauge IV needle.

Set the IV infusion pump to administer the blood over 6 hr.

Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion.

Answer and Explanation

The Correct Answer is D

A) Check the client’s vital signs from the previous shift prior to the initiation of the transfusion: Checking the client’s vital signs from the previous shift is not sufficient. The nurse should obtain a set of baseline vital signs immediately before starting the transfusion to monitor for any changes or reactions during the procedure.

B) Administer the blood via a 21-gauge IV needle: A 21-gauge IV needle is too small for administering packed RBCs. A larger gauge needle, such as an 18- or 20-gauge, is recommended to ensure the blood flows smoothly and to reduce the risk of hemolysis.

C) Set the IV infusion pump to administer the blood over 6 hr: Administering the blood over 6 hours is not appropriate. Packed RBCs should be transfused within 4 hours to reduce the risk of bacterial contamination and ensure the blood remains viable.

D) Flush the blood administration tubing with 0.9% sodium chloride prior to the transfusion: Flushing the blood administration tubing with 0.9% sodium chloride is the correct action. This helps to clear the line of any residual substances and ensures that the blood product is delivered effectively and safely to the client.

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Correct Answer is C

Explanation

A. Place the blood bag in a biohazard bag before discarding: While proper disposal of blood products is important, the immediate priority after stopping the transfusion is to ensure the patient's safety and document the reaction. The blood bag should be sent for analysis, but this action does not address the immediate next steps for patient care.

B. Administer epinephrine subcutaneously: This is not the first action unless the client is experiencing an anaphylactic reaction, which is not indicated in this scenario. The reaction described is more consistent with a febrile non-hemolytic transfusion reaction.

C. Document the reaction in the medical record: This is the most appropriate action following the cessation of the transfusion. Accurate documentation of the reaction ensures that all healthcare providers are informed of the client’s status and the incident, which is critical for ongoing care and safety.

D. Infuse 500 ml. lactated Ringer's IV: While providing IV fluids may be necessary to maintain venous access or manage symptoms, the immediate action after stopping the transfusion should focus on documenting the reaction and notifying the healthcare provider, as appropriate interventions can then be determined.

Correct Answer is ["2"]

No explanation

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A nurse is caring for an adult client who has chronic anemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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