A nurse is preparing to initiate a transfusion of packed RBC for a patient who has anemia. Which of the following actions should the plan to nurse take?
Infuse the transfusion at a rate of 200 mL/hr.
Check the patient's vital signs every hour during the transfusion.
Leave the patient 5 minutes after beginning the transfusion.
Flush the blood tubing with dextrose 5% in water.
The Correct Answer is B
A. Infuse the transfusion at a rate of 200 mL/hr. – Incorrect. The initial infusion should be slow (e.g., 75-100 mL/hr) to monitor for reactions.
B. Check the patient's vital signs every hour during the transfusion. – Correct Answer. Frequent monitoring is necessary to detect adverse reactions, such as fever or hypotension.
C. Leave the patient 5 minutes after beginning the transfusion. – Incorrect. The nurse should remain with the patient for the first 15 minutes, as most transfusion reactions occur early.
D. Flush the blood tubing with dextrose 5% in water. – Incorrect. Only normal saline should be used to flush blood tubing, as dextrose can cause hemolysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect. Never insert anything into a seizing patient's mouth, as it can cause injury.
B. Incorrect. The bed should be in the lowest position to prevent falls.
C. Incorrect. Keeping lights on is unnecessary and can cause sensory overstimulation.
D. Correct. IV access is important in case emergency medications (e.g., lorazepam) are needed during a seizure.
Correct Answer is B
Explanation
A. Allergic – An allergic reaction typically presents with itching, rash, and wheezing rather than fever, chills, and hematuria.
B. Hemolytic – Correct Answer. A hemolytic reaction occurs when the immune system attacks transfused red blood cells due to incompatibility. Symptoms include fever, chills, hypotension, back pain, and hematuria (red-tinged urine). This is a medical emergency requiring immediate intervention.
C. Acute pain – Acute pain transfusion reaction is rare and mainly presents with severe chest, back, and joint pain, without fever or hematuria.
D. Febrile – Febrile reactions cause fever and chills but do not typically cause hematuria, which is indicative of hemolysis.
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