A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?

Administer the blood transfusion slowly to observe for any reactions.

Discontinue the blood transfusion immediately and return the blood to the blood bank.

Increase the infusion rate to flush out the incompatibility.

Mix the incompatible blood with normal saline before transfusion.

Answer and Explanation

The Correct Answer is B

A) Incorrect: Administering the blood transfusion when agglutination and incompatibility are detected is unsafe and may lead to severe transfusion reactions. The nurse should not proceed with the transfusion.

B) Correct: In the presence of agglutination and incompatibility between the donor's red blood cells and the client's plasma, the nurse must discontinue the blood transfusion immediately and return the blood to the blood bank. This ensures the client's safety and prevents further adverse reactions.

C) Incorrect: Increasing the infusion rate will not resolve the incompatibility issue and may worsen the client's condition. The nurse should stop the transfusion promptly.

D) Incorrect: Mixing the incompatible blood with normal saline will not resolve the incompatibility issue and is not a safe practice. The nurse should not proceed with the transfusion and should return the blood to the blood bank.

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Correct Answer is C

Explanation

A) Incorrect: Fresh Frozen Plasma (FFP) is not the appropriate blood product for immediate volume replacement. It contains clotting factors and is used to manage bleeding disorders.

B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction and do not provide volume replacement.

C) Correct: Packed Red Blood Cells (PRBCs) contain red blood cells and are used for volume replacement in clients with acute blood loss or anemia.

D) Incorrect: Albumin is used for volume expansion in cases of hypoalbuminemia and fluid resuscitation in certain situations, but PRBCs are more effective for rapid volume replacement.

A. Administering antipyretics to reduce fever. B. Preparing to administer a diuretic to manage fluid overload. C. Monitoring the client's vital signs frequently. D. Administering epinephrine to counteract an allergic reaction.

Correct Answer is C

Explanation

A) Incorrect: Administering antipyretics to reduce fever is not the appropriate intervention for an acute hemolytic transfusion reaction. This type of reaction involves the destruction of red blood cells, not an elevation in body temperature.

B) Incorrect: Preparing to administer a diuretic is not the appropriate intervention for an acute hemolytic transfusion reaction. Fluid overload is not a typical feature of this type of reaction.

C) Correct: Monitoring the client's vital signs frequently is a crucial intervention for an acute hemolytic transfusion reaction. This type of reaction can cause rapid onset of severe symptoms, including fever, chills, hypotension, tachycardia, and potential shock.

D) Incorrect: Administering epinephrine is not the appropriate intervention for an acute hemolytic transfusion reaction. Epinephrine is used to treat anaphylactic reactions, not hemolytic reactions.

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A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client requires immediate volume replacement due to hypovolemic shock. Which blood product should the nurse anticipate administering to rapidly restore intravascular volume?

Correct Answer is C

Explanation

A nurse is caring for a client who experiences an acute hemolytic transfusion reaction. What intervention should the nurse anticipate implementing?

Correct Answer is C

Explanation

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