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 D
Explanation
Choice A rationale
A client's age is a non-modifiable risk factor for stroke. The risk of stroke generally increases with advancing age due to the cumulative effects of various physiological changes and increased prevalence of underlying cardiovascular conditions. This factor cannot be changed or controlled by lifestyle modifications.
Choice B rationale
Sickle cell disease is a genetic, non-modifiable risk factor for stroke. The abnormal shape of red blood cells in sickle cell disease can lead to vaso-occlusion and increased risk of ischemic stroke, particularly in children. While treatments exist, the underlying genetic predisposition remains.
Choice C rationale
A family history of cardiovascular disease, such as a parent with the condition, indicates a genetic predisposition and is a non-modifiable risk factor for stroke. While genetic factors play a role in cardiovascular health, this specific family history cannot be altered through lifestyle or medical interventions.
Choice D rationale
Hypertension is a modifiable risk factor for stroke because it can be managed and controlled through lifestyle modifications, such as diet and exercise, and pharmacotherapy. Chronic uncontrolled hypertension damages blood vessels, leading to atherosclerosis and increasing the risk of both ischemic and hemorrhagic strokes.
Correct Answer is A
Explanation
Choice A rationale
A myasthenic crisis is a life-threatening exacerbation of myasthenia gravis characterized by severe muscle weakness, particularly affecting the respiratory muscles. This can lead to impending or actual respiratory failure, necessitating immediate intervention with mechanical ventilation to support breathing and prevent hypoxemia and hypercapnia.
Choice B rationale
A vasoconstrictor would elevate blood pressure by constricting blood vessels. Myasthenic crisis primarily involves profound muscle weakness, not typically hypotensive states requiring vasoconstrictors. Administering a vasoconstrictor would not address the underlying respiratory compromise or muscle weakness.
Choice C rationale
Pursed-lip breathing is a technique used to prolong exhalation and improve ventilation in individuals with obstructive lung diseases like COPD. While it can help with dyspnea, it is insufficient to manage the severe respiratory muscle weakness seen in a myasthenic crisis and would not prevent respiratory failure.
Choice D rationale
Sedatives depress the central nervous system and can further impair respiratory drive and muscle function, which would be detrimental in a myasthenic crisis. The client's respiratory status is already compromised, and sedation would exacerbate hypoventilation and increase the risk of respiratory arrest.
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