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) Incorrect: A slight increase in blood pressure is not a significant vital sign alteration that requires immediate reporting before initiating the transfusion. It could be related to various factors, such as anxiety or pain.

B) Incorrect: A respiratory rate of 22 breaths per minute is within the normal range for an adult and does not require immediate reporting before starting the transfusion.

C) Incorrect: A decrease in heart rate from 88 to 72 beats per minute is not a critical vital sign alteration. As long as the heart rate remains within the client's baseline range, it does not need immediate reporting.

D) Correct: An elevated temperature of 38.5°C (101.3°F) may indicate a fever, which could be a sign of an infection or an adverse reaction to the transfusion. The nurse should report this vital sign alteration to the healthcare provider before proceeding with the transfusion to determine the appropriate course of action.

A. A-negative (A-), B-negative (B-), AB-positive (AB+), and O-positive (O+). B. A-positive (A+), AB-negative (AB-), O-positive (O+), and B-negative (B-). C. AB-negative (AB-), O-positive (O+), AB-positive (AB+), and B-positive (B+). D. O-negative (O-), B-positive (B+), and O-positive (O+). E. None F. None

Correct Answer is D

Explanation

A. A-negative (A-) and AB-positive (AB+) are incompatible with B-positive (B+), as individuals with B+ blood can only receive blood from B or O types.
B. A-positive (A+) and AB-negative (AB-) are incompatible for the same reason.
C. AB-negative (AB-) and AB-positive (AB+) are not suitable donors for B-positive (B+) recipients.
D. O-negative (O-), B-positive (B+), and O-positive (O+) are all compatible with B-positive (B+), making this the correct choice.

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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 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?

Correct Answer is D

Explanation

A client with blood type B-positive (B+) requires a blood transfusion. Which blood types are compatible with this client for a crossmatch?

Correct Answer is D

Explanation

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