A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client with severe anemia. Before starting the blood transfusion, the nurse should:
Obtain the client's informed consent for the blood transfusion.
Confirm the client's blood type and Rh factor with the blood bank.
Administer pre-medication to prevent transfusion reactions.
Assess the client's blood pressure and heart rate.
Correct Answer : A,B,D
A) Obtaining the client's informed consent is a critical step before any medical procedure, including blood transfusions. This ensures the client understands the risks and benefits of the transfusion and gives their consent willingly.
B) Confirming the client's blood type and Rh factor with the blood bank is essential to prevent transfusion reactions. Mismatching blood types can lead to severe transfusion reactions and is a crucial step in the transfusion process.
C) Administering pre-medication to prevent transfusion reactions is not a standard practice. However, the nurse should assess the client for any risk factors or history of previous transfusion reactions to take appropriate precautions.
D) Assessing the client's blood pressure and heart rate is an important part of the overall assessment before the blood transfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect: Fever and chills during a blood transfusion may be signs of a febrile transfusion reaction, not an allergic reaction. The nurse should provide information specific to preventing allergic reactions.
B) Correct: Itching, rash, and facial swelling are common signs of an allergic transfusion reaction. The nurse should instruct the client to notify the healthcare provider immediately if they experience these symptoms.
C) Incorrect: A brief period of increased heart rate after the transfusion may be normal, but it is not specific to preventing an allergic transfusion reaction. The nurse should focus on providing information about allergic reaction symptoms.
D) Incorrect: Lower back pain is not typically associated with allergic transfusion reactions. The nurse should provide information about symptoms that indicate an allergic reaction, such as itching, rash, and facial swelling.
Correct Answer is B
Explanation
A) Incorrect: Administering a bolus of normal saline may help increase intravascular volume, but it is not the first intervention to be implemented. The nurse should first identify the cause of the client's symptoms and take appropriate actions.
B) Correct: The client's symptoms of feeling lightheaded and dizzy, along with a drop in blood pressure and an increase in heart rate, suggest orthostatic hypotension. The nurse's first intervention should be to elevate the client's feet and lower the head to improve blood flow to the brain.
C) Incorrect: Checking the client's hemoglobin and hematocrit levels is essential but may not be the first intervention in this situation. The client's symptoms indicate an immediate need to address the orthostatic hypotension.
D) Incorrect: Notifying the healthcare provider for further evaluation is important, but it may not be the first intervention. The nurse should first take immediate actions to address the client's symptoms of orthostatic hypotension.
Questions
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