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

Verify the client's identity and blood type with two unique identifiers.

Confirm the expiration date of the blood product.

Assess the client's vital signs, including temperature, pulse, and blood pressure.

Obtain informed consent from the client for the blood transfusion.

Answer and Explanation

The Correct Answer is A

A) Correct: The nurse should 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. This step ensures that the correct blood product is administered to the right client, promoting safety.

B) Incorrect: Confirming the expiration date of the blood product is important but not the first step in ensuring client safety during a blood transfusion. The nurse should first verify the client's identity and blood type.

C) Incorrect: Assessing the client's vital signs is essential, but it is not the first action to be taken. Verifying the client's identity and blood type is the priority before starting the transfusion.

D) Incorrect: Obtaining informed consent from the client is crucial but not the first action to be taken. The nurse should first verify the client's identity and blood type before seeking consent for the transfusion.

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Correct Answer is D

Explanation

A. A-negative (A-), B-negative (B-), AB-negative (AB-), and O-positive (O+) are all compatible with AB-positive (AB+) since AB+ individuals can receive any blood type.
B. A-positive (A+), O-negative (O-), AB-negative (AB-), and B-positive (B+) are also compatible for the same reason.
C. A-negative (A-), B-positive (B+), AB-negative (AB-), and O-positive (O+) are all suitable donor types.
D. AB-positive (AB+) is the universal recipient and can receive blood from any blood type.

A. Notify the healthcare provider immediately to obtain a blood transfusion order. B. Administer supplemental oxygen to the client to improve oxygenation. C. Initiate intravenous access with a large-bore catheter for possible transfusion. D. Encourage the client to ambulate to improve blood circulation.

Correct Answer is A

Explanation

A: Notify the healthcare provider immediately to obtain a blood transfusion order – This is the priority action because the client’s hemoglobin level of 8 g/dL, along with symptoms of hypoxia, indicates a need for urgent medical intervention. Obtaining an order for a transfusion is crucial for addressing the underlying issue of low hemoglobin and associated hypoxia.
B: Administer supplemental oxygen to the client to improve oxygenation – While this action is important, it is not the first step. The low hemoglobin indicates a need for a transfusion, and notifying the provider can lead to quicker treatment.
C: Initiating IV access with a large-bore catheter is an important step in preparation for a possible blood transfusion, but it is not the first action. The client's current symptoms must be managed promptly.
D: Ambulation may be contraindicated post-major surgery, especially when the client is symptomatic. It could exacerbate the client's condition and is not the immediate priority in this scenario.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with blood type AB-positive (AB+) requires a blood transfusion. Which blood types can safely donate to this client?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

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