A nurse is preparing to administer a blood transfusion to a client. Which action should the nurse take before initiating the transfusion?

Confirm the client's identity and blood type with the client's family member.

Obtain informed consent from the client and ensure the client has a signed consent form.

Warm the blood unit to body temperature in a microwave oven to prevent hypothermia.

Administer a rapid bolus of normal saline to prime the client's veins.

Answer and Explanation

The Correct Answer is B

A) Incorrect: Confirming the client's identity and blood type with the client's family member is not a reliable method for ensuring patient safety during a blood transfusion. The nurse should directly verify the client's identity and blood type with two unique identifiers, such as asking the client to state their full name and date of birth and comparing it to their identification band.

B) Correct: Obtaining informed consent from the client is a crucial step before initiating a blood transfusion. The nurse must ensure the client understands the risks and benefits of the transfusion and has willingly provided consent. A signed consent form is the formal documentation of this process.

C) Incorrect: Warming blood in a microwave oven is not an appropriate method for preventing hypothermia and can lead to hemolysis of the blood components. Blood should be warmed using an approved blood warmer designed for this purpose.

D) Incorrect: Administering a rapid bolus of normal saline is unnecessary and could lead to fluid overload in the client. The nurse should administer normal saline or another appropriate IV fluid at the prescribed rate if the client requires hydration before or after the transfusion, but not as a priming method.

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Correct Answer is B

Explanation

A) Incorrect: A mild headache is a common and expected side effect of a blood transfusion and may not require immediate reporting to the healthcare provider.

B) Correct: A slightly elevated temperature in a client who received a blood transfusion 2 hours ago could indicate a delayed transfusion reaction. The nurse should report this finding to the healthcare provider for further evaluation.

C) Incorrect: Pale and cool skin may be an expected finding in a client who received a blood transfusion, especially if they experienced a rapid transfusion or had a reaction. However, it is not the priority finding to report.

D) Incorrect: Generalized muscle weakness may occur for various reasons and may not be directly related to a delayed transfusion reaction. The nurse should prioritize reporting the slightly elevated temperature.

A. Stop the transfusion immediately and notify the healthcare provider. B. Administer an antihistamine to manage the allergic reaction. C. Slow down the transfusion rate to observe for further reactions. D. Place the client in a supine position with legs elevated.

Correct Answer is A

Explanation

A) Correct: The client's symptoms of hives, itching, and facial swelling indicate a potential allergic transfusion reaction (urticarial reaction). The nurse's immediate action is to stop the transfusion immediately and notify the healthcare provider for further evaluation and intervention.

B) Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic transfusion reaction, it is not the immediate action. The nurse should first stop the transfusion and notify the healthcare provider.

C) Incorrect: Slowing down the transfusion rate is not appropriate in the presence of an allergic transfusion reaction. The nurse should stop the transfusion immediately.

D) Incorrect: Placing the client in a supine position with legs elevated is not indicated for an allergic transfusion reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.

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A nurse is preparing to administer a blood transfusion to a client. Which action should the nurse take before initiating the transfusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client received a blood transfusion 2 hours ago. The nurse is assessing for signs of a delayed transfusion reaction. Which assessment finding should the nurse report to the healthcare provider?

Correct Answer is B

Explanation

A nurse is monitoring a client during a blood transfusion. The client suddenly develops hives, itching, and facial swelling. What is the nurse's immediate action?

Correct Answer is A

Explanation

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