Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to ensure patient safety?

Check the identifying information on the unit of blood against the patient’s ID bracelet

Stay with the patient for 60 minutes after starting the transfusion

Add the blood transfusion as a secondary line to the existing IV.

Prime new primary IV tubing with lactated Ringer's Solution to use for the transfusion

Answer and Explanation

The Correct Answer is A

A) Check the identifying information on the unit of blood against the patient’s ID bracelet:
This is the highest priority to ensure patient safety before beginning a transfusion. The risk of transfusion reactions, including hemolytic reactions due to mismatched blood, makes verifying patient identification critical. The nurse must match the blood product with the patient’s information and confirm that the blood product is correct for the patient. This verification is typically done with a second nurse to ensure safety. If the blood is mismatched, it can lead to severe, potentially life-threatening consequences.

B) Stay with the patient for 60 minutes after starting the transfusion:
While it is important to stay with the patient during the transfusion and monitor for adverse reactions, the highest priority before starting the transfusion is verifying patient and blood product compatibility. After starting the transfusion, staying with the patient for the first 15 minutes is critical for monitoring for early signs of a transfusion reaction, but this action occurs after the blood has been correctly matched and started.

C) Add the blood transfusion as a secondary line to the existing IV:
Ensuring proper identification and blood product matching is more critical than deciding whether to use a secondary IV line. The nurse should verify patient and blood compatibility first and then proceed with setting up the IV line for transfusion.

D) Prime new primary IV tubing with lactated Ringer's solution to use for the transfusion:
Priming IV tubing with lactated Ringer’s solution is incorrect for a blood transfusion. Blood should only be administered with normal saline, as other fluids, including lactated Ringer's solution, can cause clotting or hemolysis when mixed with blood products. This action would not be a safe or appropriate step in preparing for a blood transfusion. The correct solution to prime tubing for blood transfusions is normal saline, and this is secondary to ensuring proper patient identification and blood compatibility.

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Correct Answer is D

Explanation

A) "The medication should be given with 5-6 hours of the onset of stroke symptoms":
. tPA (tissue plasminogen activator) is typically given for an ischemic stroke, and it is most effective when administered within 3 to 4.5 hours of the onset of stroke symptoms. After this time frame, the risk of bleeding complications increases, and the benefits of the medication diminish significantly. Giving tPA after 6 hours is generally considered outside the therapeutic window for ischemic stroke, though some centers may extend the window based on specific criteria.

B) "The medication is a primary treatment for hemorrhagic stroke":
. tPA is contraindicated in hemorrhagic stroke because it works by dissolving clots, which could worsen bleeding in the brain. Hemorrhagic stroke occurs when there is bleeding in the brain, and administering tPA would exacerbate the bleeding, leading to more severe brain injury and complications. The primary treatment for hemorrhagic stroke is controlling bleeding, often through surgical interventions or managing blood pressure.

C) "The medication can be given to prevent clot formation in the context of head trauma":
. tPA is not used to prevent clot formation, particularly in the setting of head trauma. It is used to dissolve existing clots in cases of ischemic stroke. Administering tPA after head trauma or brain injury could lead to catastrophic complications, such as worsening bleeding, and should be avoided. The use of tPA is contraindicated in trauma-related situations unless the stroke is clearly ischemic and there are no signs of hemorrhage.

D) "When given within a certain timeframe, the medication may dissolve an ischemic stroke":
. tPA is the standard treatment for ischemic strokes (caused by a clot blocking blood flow to the brain). When administered within 3 to 4.5 hours of the onset of symptoms, tPA can dissolve the clot, improving blood flow to the affected area of the brain and potentially minimizing the damage caused by the stroke. Timely administration is critical for maximizing its benefits in reducing disability and improving outcomes.

A. Simvastatin B. Metoprolol C. Acetylsalicylic. Acid (Aspirin) D. Metformin

Correct Answer is B

Explanation

A) Simvastatin: Simvastatin is a medication used to lower cholesterol levels and does not typically require monitoring of blood pressure before or after administration. While statins may have some indirect cardiovascular benefits, blood pressure is not directly affected by this medication, so it is not necessary to assess blood pressure before or after administering simvastatin.

B) Metoprolol: This is the correct answer. Metoprolol is a beta-blocker commonly used to treat hypertension and other cardiovascular conditions. It works by reducing heart rate and blood pressure. Therefore, it is important to assess the client's blood pressure both before and after administering metoprolol to ensure the medication is having the desired effect and to detect any adverse changes, such as hypotension or bradycardia.

C) Acetylsalicylic Acid (Aspirin): Aspirin is primarily used for its antiplatelet effect, such as for preventing heart attacks or strokes, and it does not have a significant direct impact on blood pressure. While aspirin can have side effects, such as gastrointestinal irritation or bleeding, blood pressure monitoring is generally not necessary before or after administering aspirin.

D) Metformin: Metformin is used to manage type 2 diabetes by helping control blood glucose levels. It does not directly affect blood pressure, so routine blood pressure assessment is not required before or after giving metformin. However, monitoring for side effects like gastrointestinal distress or lactic acidosis is important, but blood pressure is not a priority for this medication.

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Before beginning a transfusion of packed red blood cells (PRBCs), which action by the nurse would be of highest priority to ensure patient safety?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

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