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 A

Explanation

A. Have the client lay prone for 30 minutes. 3-4 times a day:
This statement is correct. Lying prone (on the stomach) for 30 minutes several times a day helps to prevent hip flexion contractures, which are common complications after an above-the-knee amputation. By lying prone, the residual limb is stretched and the hip joint is kept in an extended position, which helps maintain proper alignment and reduces the risk of contractures. This is a key part of postoperative care to promote optimal positioning and rehabilitation.

B. Continue using the limb prosthesis even if the skin appears irritated:
This statement is incorrect. If the skin becomes irritated or damaged, the prosthesis should not be used until the skin has healed. Continued use of the prosthesis in the presence of skin irritation can cause further damage, leading to ulcers or infections. It is essential to regularly check the residual limb for irritation, redness, or sores and adjust the prosthesis as needed. If irritation is present, the prosthesis should be removed, and appropriate skin care should be provided.

C. Withhold medication for phantom limb pain as it isn't real pain:
This statement is incorrect. Phantom limb pain is real and a common experience for individuals after an amputation. It occurs when the brain perceives pain sensations in the area where the limb used to be, even though the limb is no longer there. Phantom limb pain is often treated with pain medications, including analgesics, anticonvulsants, or antidepressants, and should not be withheld. Proper management of phantom limb pain is important for the client's comfort and overall well-being.

D. Keep the residual limb elevated to achieve as close to 90-degree hip flexion as possible:
This statement is incorrect. While it is important to elevate the residual limb after surgery to reduce swelling, it should not be elevated to the point where the hip joint is flexed to 90 degrees. Elevating the limb too much or for prolonged periods can increase the risk of developing a hip flexion contracture, which would impair mobility. The residual limb should be elevated slightly, but the hip joint should not be excessively flexed. Ideally, the limb should be positioned in a neutral or extended position when elevated.

A. "Be sure to bend at the hip, not the knee, to pick up items." B. internally rotating your leg is okay, but do not externally rotate it." C. If we need so help you roll in bed, we will roll you towards the operative side. D. You should keep your knees apart using a wedge or pillow.

Correct Answer is D

Explanation

A) "Be sure to bend at the hip, not the knee, to pick up items."
After hip replacement surgery, patients are instructed to avoid bending at the hip beyond 90 degrees, as this can dislocate the newly replaced hip. The correct guidance would be to avoid bending at the hip and instead bend at the knee when picking up items, ensuring the hip joint stays in a safe position.

B) "Internally rotating your leg is okay, but do not externally rotate it."
Internal rotation of the hip joint should also be avoided post-surgery, as it can increase the risk of dislocation. The correct teaching is to prevent both internal and external rotation of the hip to ensure the joint remains stable. Patients should be instructed to avoid twisting motions that can compromise the surgical repair.

C) "If we need to help you roll in bed, we will roll you towards the operative side."
This can place undue pressure on the newly replaced hip, potentially leading to dislocation or injury. The operative side should be kept stable and protected, so it is safer to roll the patient onto the non-operative side if necessary.

D) "You should keep your knees apart using a wedge or pillow."
It is essential to keep the knees apart, typically using a wedge or pillow between the legs. This prevents the hip from adducting (moving toward the midline) and reducing the risk of dislocation. Maintaining this position ensures the hip remains in a safe, stable alignment during the healing process.

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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

Which of the following interventions should the nurse include when caring for a client who is returning from surgery for an above-the-knee amputation?

Correct Answer is A

Explanation

Which of the following should be included in patient teaching after hip replacement surgery?

Correct Answer is D

Explanation

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