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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Free Nursing Study Resources

Correct Answer is A

Explanation

A) Correct: The client's symptoms of respiratory distress and chest pain indicate a potential transfusion-related acute lung injury (TRALI), a severe transfusion reaction. The nurse's priority intervention is to administer oxygen via a non-rebreather mask to improve oxygenation.

B) Incorrect: Discontinuing the blood transfusion immediately is necessary in suspected cases of TRALI, but it is not the priority intervention. First, the nurse should provide immediate respiratory support by administering oxygen.

C) Incorrect: Elevating the client's feet and lowering the head (Trendelenburg position) is not indicated for TRALI. It may be used for clients in shock, but the priority is to manage the client's respiratory distress and chest pain.

D) Incorrect: Administering diuretics is not the priority intervention for TRALI. TRALI is caused by a reaction to plasma components, not fluid overload, and diuretics may not address the underlying cause.

A. Administering antipyretics to reduce fever. B. Preparing to administer a diuretic to manage fluid overload. C. Monitoring the client's vital signs frequently. D. Administering epinephrine to counteract an allergic reaction.

Correct Answer is C

Explanation

A) Incorrect: Administering antipyretics to reduce fever is not the appropriate intervention for an acute hemolytic transfusion reaction. This type of reaction involves the destruction of red blood cells, not an elevation in body temperature.

B) Incorrect: Preparing to administer a diuretic is not the appropriate intervention for an acute hemolytic transfusion reaction. Fluid overload is not a typical feature of this type of reaction.

C) Correct: Monitoring the client's vital signs frequently is a crucial intervention for an acute hemolytic transfusion reaction. This type of reaction can cause rapid onset of severe symptoms, including fever, chills, hypotension, tachycardia, and potential shock.

D) Incorrect: Administering epinephrine is not the appropriate intervention for an acute hemolytic transfusion reaction. Epinephrine is used to treat anaphylactic reactions, not hemolytic reactions.

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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 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?

Correct Answer is A

Explanation

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

Correct Answer is C

Explanation

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A nurse is preparing to initiate a blood transfusion for a client. Which action should the nurse take first to ensure client safety?

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 expresses anxiety and fear about receiving a blood transfusion. What action should the nurse take to address the client's concerns?

A client has a history of severe allergic reactions and is scheduled to receive a blood transfusion. What intervention should the nurse implement to prevent an allergic transfusion reaction in this client?

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?