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 C

Explanation

A) Incorrect: Iron-deficiency anemia is not a contraindication for a blood transfusion. In fact, it is one of the common indications for transfusion in clients with severe anemia.

B) Incorrect: Chronic kidney disease is not a contraindication for a blood transfusion. Transfusions may be necessary for clients with chronic kidney disease who develop anemia due to decreased erythropoietin production.

C) Correct: Hemolytic anemia is a contraindication for a blood transfusion. This condition involves the destruction of red blood cells, and a transfusion with incompatible blood can worsen the hemolysis and lead to a severe transfusion reaction.

D) Incorrect: Hypertension is not a contraindication for a blood transfusion. While the nurse should monitor blood pressure during the transfusion, hypertension alone does not preclude the need for a transfusion in a client with other indications for blood products.

A. Administer epinephrine immediately. B. Stop the transfusion and disconnect the IV tubing. C. Slow down the transfusion rate. D. Obtain a blood sample for repeat crossmatching.

Correct Answer is C

Explanation

A) Incorrect: Administering epinephrine is not the appropriate intervention for an allergic transfusion reaction characterized by urticaria and itching. Epinephrine is used to treat anaphylactic reactions.

B) Incorrect: Stopping the transfusion and disconnecting the IV tubing is appropriate in the event of an allergic transfusion reaction, but it should not be the first action. The nurse should first slow down or stop the transfusion if mild symptoms are present and notify the healthcare provider for further instructions.

C) Correct: Slowing down the transfusion rate may be appropriate for mild allergic reactions to reduce symptoms. However, if the reaction worsens, the nurse should stop the transfusion immediately.

D) Incorrect: Obtaining a blood sample for repeat crossmatching is not indicated in an allergic transfusion reaction. Allergic reactions are related to hypersensitivity to plasma proteins and do not involve compatibility issues between red blood cells and plasma.

Questions

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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 nurse is assessing a client's history before a blood transfusion. Which condition should the nurse identify as a contraindication for transfusion?

Correct Answer is C

Explanation

A nurse is caring for a client who develops urticaria (hives) and itching during a blood transfusion. The nurse suspects an allergic transfusion reaction. What is the appropriate nursing action?

Correct Answer is C

Explanation

A nurse is preparing to administer a blood transfusion to a client. Which vital sign alteration should the nurse report to the healthcare provider before initiating the transfusion?

A client receiving a blood transfusion suddenly becomes agitated, dyspneic, and reports a sense of impending doom. The nurse assesses the client and notes jugular vein distention and muffled heart sounds. What action should the nurse take next?

A nurse is caring for a client who experiences an acute hemolytic transfusion reaction. What intervention should the nurse anticipate implementing?

A client receiving a blood transfusion suddenly develops chills, fever, and lower back pain. The nurse suspects a transfusion reaction. What is the nurse's priority action?

A client develops respiratory distress and chest pain during a blood transfusion. The nurse suspects a transfusion-related acute lung injury (TRALI). What is the nurse's priority intervention?

A nurse is caring for a client who has undergone major surgery and has a hemoglobin level of 8 g/dL. The client is experiencing symptoms of hypoxia, including tachycardia and shortness of breath. The nurse suspects the need for a blood transfusion. What action should the nurse take first?

A nurse is assessing a client who just received a blood transfusion. The client complains of back pain, fever, and chills. What action should the nurse take first?

A nurse is caring for a client who experienced a mild allergic reaction during a blood transfusion. Which action should the nurse take to prevent future allergic reactions in this client?