A nurse is preparing to administer packed RBCs to a client who has a low hemoglobin level. Which of the following actions should the nurse take prior to the start of the infusion?
Check that the client has a small gauge IV catheter in place.
Check the blood product's compatibility with the client's blood type.
Prime the client's primary IV tubing with lactated Ringer's.
Confirm the identity of the client with the blood bank technician.
The Correct Answer is B
A. Check that the client has a small gauge IV catheter in place.
Blood transfusions require a large-bore IV catheter (18-20 gauge) to prevent hemolysis and ensure efficient infusion. A small gauge IV (such as 22-24G) is not appropriate for PRBCs as it can slow the infusion and damage red blood cells.
B. Check the blood product's compatibility with the client's blood type: Before administering packed red blood cells (PRBCs), the nurse must verify blood compatibility to prevent a hemolytic transfusion reaction, which can be life-threatening.
C. Prime the client's primary IV tubing with lactated Ringer’s.
Only normal saline (0.9% NaCl) should be used to prime the IV tubing for a blood transfusion. Lactated Ringer’s and dextrose solutions can cause hemolysis and clotting of the blood product.
D. Confirm the identity of the client with the blood bank technician. While verifying the blood product is critical, the nurse should confirm the client’s identity at the bedside with another licensed nurse, not the blood bank technician. This ensures that the right blood is given to the right client following facility protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Correct responses:
A. When preparing the medication dosage: Comparing the medication administration record with the medication label during preparation helps ensure the correct medication and dosage are being used.
B. Directly before administering the medication: This final check ensures that the medication being given matches the prescription and the right patient, minimizing the risk of errors.
D. When removing the medication from the medication drawer: This initial check ensures that the medication being retrieved is the correct one as per the medication administration record.
The other options are not directly related to verifying the medication administration record against the medication label:
C. When reconciling counts of controlled substances: This is important for ensuring accurate inventory but is not related to verifying medication administration.
E. At the end of the shift: This is not a time for verifying medication records and labels; it’s more related to end-of-shift documentation and handoff.
Correct Answer is D
Explanation
A. Direct a fire extinguisher at the fire:
While using a fire extinguisher is an essential action in controlling a small fire, it should come after the fire alarm has been activated. Alerting others to the fire and initiating the emergency response system take precedence to ensure a coordinated and safe response.
B. Place wet towels along the base of the door:
Placing wet towels along the base of the door is a method to help prevent smoke from entering the room. However, in this situation, after ensuring the client's safety, the nurse should focus on activating the facility's fire alarm to alert others and initiate the emergency response.
C. Turn off any electrical equipment:
While turning off electrical equipment is a generally sound practice in fire safety, it is not the immediate next action after moving the client to safety. Activating the fire alarm takes precedence as it initiates a coordinated response and alerts others to the emergency.
D. Activate the facility's fire alarm:
This is the correct action. Activating the fire alarm is a critical step in alerting the entire facility to the presence of a fire. It ensures that emergency response teams are notified promptly, and appropriate measures can be taken to address the fire, including evacuating other occupants and summoning professional firefighting assistance.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
