A nurse is preparing to administer a blood transfusion to a client with significant blood loss. What is the nurse's most important action before starting the transfusion?

Check the client's blood pressure.

Verify the client's identification using two identifiers.

Assess the client's oxygen saturation level.

Obtain consent for the blood transfusion.

Answer and Explanation

The Correct Answer is B

A) Incorrect. Checking the client's blood pressure is important but not the most critical action before starting a blood transfusion.

B) Correct. The most crucial step before administering any intervention, including a blood transfusion, is to verify the client's identification using two identifiers (e.g., name and date of birth or medical record number) to ensure the right blood is given to the right client.

C) Incorrect. While assessing the client's oxygen saturation is important, it is not the priority before starting a blood transfusion.

D) Incorrect. Obtaining consent for the blood transfusion is essential, but verifying the client's identification is more critical before administering the transfusion.

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Correct Answer is C

Explanation

A) Incorrect. Administering oxygen is essential for a client experiencing difficulty breathing, but the nurse's immediate action should be to stop the blood transfusion and notify the healthcare provider.

B) Incorrect. While assessing the client's vital signs is important, the priority action is to stop the blood transfusion and seek immediate medical assistance.

C) Correct. Sudden difficulty breathing and chest pain after a blood transfusion may indicate an allergic reaction or transfusion-related acute lung injury (TRALI). The nurse should stop the transfusion immediately and inform the healthcare provider.

D) Incorrect. Elevating the head of the client's bed may be helpful in managing respiratory distress, but it is not the priority when there is a potential adverse reaction to the blood transfusion.

A. Administer pain medication to alleviate discomfort. B. Assist the client to a comfortable position in bed. C. Apply direct pressure to the bleeding site. D. Obtain a detailed health history from the client.

Correct Answer is C

Explanation

A) Incorrect. While pain management is essential, it is not the priority when dealing with active bleeding that requires immediate intervention.

B) Incorrect. Positioning the client comfortably is important, but it is not the priority when there is active bleeding.

C) Correct. The priority intervention is to apply direct pressure to the bleeding site to control and reduce bleeding until further assessment and medical assistance can be obtained.

D) Incorrect. Obtaining a detailed health history is valuable for understanding the client's overall health, but it is not the priority when the client is actively bleeding and requires immediate intervention.

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A nurse is preparing to administer a blood transfusion to a client with significant blood loss. What is the nurse's most important action before starting the transfusion?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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