A nurse is planning to perform a blood transfusion for a client.
Which of the following actions should the nurse plan to take? (Select all that apply.)
Check the expiration date of the blood product with a second nurse.
Prime the blood tubing with dextrose 5% in water.
Insert an IV with a 20-gauge or larger needle.
Transfuse the blood product within 5 hours after removing it from refrigeration.
Check vital signs before transfusion.
Correct Answer : A,C,E
Choice A rationale
Checking the expiration date with a second nurse is a critical safety measure, ensuring proper identification and viability of the blood product. This dual verification mitigates the risk of administering expired or incorrect blood, which could lead to severe immunological reactions such as acute hemolytic transfusion reactions due to complement activation and antigen-antibody complex formation. This adherence to protocol aligns with best practices for patient safety.
Choice B rationale
Priming blood tubing with dextrose 5% in water is contraindicated because dextrose solutions are hypotonic and can cause hemolysis of red blood cells. The osmotic gradient draws water into the erythrocytes, leading to cell lysis and the release of hemoglobin, which can result in renal damage and hyperkalemia. Normal saline (0.9% sodium chloride) is isotonic and is the only solution compatible for priming blood transfusion sets to maintain red blood cell integrity.
Choice C rationale
Inserting an IV with a 20-gauge or larger needle (e.g., 18-gauge) is recommended for blood transfusions. This larger bore minimizes shear stress on red blood cells during infusion, reducing the risk of hemolysis. Smaller gauges can cause mechanical trauma to the fragile erythrocytes as they pass through, potentially leading to the release of intracellular contents and adverse patient reactions.
Choice D rationale
Transfusing a blood product within 4 hours, not 5 hours, after removing it from refrigeration is the standard guideline. Exceeding this timeframe increases the risk of bacterial proliferation within the blood product, as temperatures rise above refrigeration levels. This can lead to severe febrile non-hemolytic transfusion reactions or even septic shock, compromising patient safety and treatment efficacy.
Choice E rationale
Checking vital signs before transfusion establishes a baseline for the client's physiological status. This baseline is essential for detecting early signs of transfusion reactions, such as fever, chills, or changes in blood pressure. Significant deviations from baseline vital signs during or after the transfusion indicate a potential adverse event, necessitating immediate intervention to ensure patient safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Paresthesia, characterized by abnormal sensations such as tingling, numbness, or "pins and needles," is a common symptom in multiple sclerosis. This occurs due to demyelination and subsequent damage to sensory nerve pathways in the central nervous system, disrupting the normal transmission of sensory signals from the periphery to the brain. These sensory disturbances can fluctuate in intensity and location.
Choice B rationale
Nausea and vomiting are generally not considered primary or common assessment findings directly related to the pathophysiology of multiple sclerosis. While a client with MS might experience nausea and vomiting due to other co-existing conditions, medication side effects, or central nervous system lesions affecting areas involved in emesis (e.g., area postrema), it is not a hallmark symptom of the disease itself.
Choice C rationale
Dysphagia, or difficulty swallowing, is a significant symptom in multiple sclerosis, especially as the disease progresses. Demyelination and lesions in the brainstem or cranial nerves responsible for coordinating the complex muscular movements of swallowing can impair the pharyngeal and esophageal phases, increasing the risk of aspiration and nutritional deficiencies.
Choice D rationale
Spasticity, an increase in muscle tone leading to stiffness and involuntary muscle spasms, is a prevalent and often debilitating symptom in multiple sclerosis. It results from damage to the corticospinal tracts, which are descending motor pathways that normally inhibit muscle stretch reflexes. The loss of this inhibition leads to hyperexcitability of muscle stretch reflexes.
Choice E rationale
Vertigo, a sensation of spinning or dizziness, is a frequent complaint in multiple sclerosis. This symptom arises from demyelination and lesions affecting the brainstem or cerebellum, which are critical structures involved in maintaining balance and coordinating movement. Damage to these areas disrupts the processing of vestibular input, leading to disequilibrium and rotational sensations.
Correct Answer is B
Explanation
Choice A rationale
Postpartum depression is a mood disorder characterized by pervasive sadness, anhedonia, and feelings of inadequacy, extending beyond transient "baby blues.”. While fatigue is a symptom, the client reports feeling well overall, which is inconsistent with the profound emotional distress typically seen in depression, where cognitive and affective symptoms dominate.
Choice B rationale
Iron deficiency anemia commonly presents with severe fatigue due to insufficient oxygen transport to tissues. During pregnancy and postpartum, increased iron demands for fetal development, blood volume expansion, and blood loss during delivery can deplete maternal iron stores, leading to a reduction in hemoglobin synthesis. Normal hemoglobin levels for postpartum women are typically >11 g/dL.
Choice C rationale
Sickle cell anemia is a genetic blood disorder characterized by abnormally shaped red blood cells that impede oxygen delivery, causing chronic fatigue and episodes of severe pain. This condition is diagnosed through genetic screening or hemoglobin electrophoresis, and its symptoms are usually chronic and profound, not typically surfacing acutely as just fatigue postpartum without prior diagnosis.
Choice D rationale
Postpartum hemorrhage is excessive bleeding after childbirth, leading to signs of hypovolemia such as tachycardia, hypotension, and pallor. While hemorrhage causes significant fatigue due to acute blood loss, the client reports feeling well overall, indicating stable vital signs and no overt signs of acute hypovolemic shock. Normal blood pressure is 90-120/60-80 mmHg.
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