The nurse is performing the safety checks prior to initiating a packed red blood cell transfusion for a patient whose blood type is A positive. The nurse observes the unit is AB negative. What is the nurse's best first action?
Call the blood bark
Initiate the transfusion
Take and record the patients vital signs
Notify the physician
The Correct Answer is A
A. The first action should be to call the blood bank to report the mismatch in blood type. The patient is A positive, and the blood unit is AB negative, which is not compatible and could lead to a serious transfusion reaction. The blood bank can provide the correct unit of blood.
B. Initiating the transfusion with the wrong blood type is dangerous and could cause a life-threatening reaction.
C. Taking and recording vital signs is important but should only occur after confirming the correct blood product. Starting a transfusion with the wrong blood is a safety hazard.
D. While notifying the physician is important, the immediate action is to contact the blood bank to resolve the blood type mismatch.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Radiation oncology is focused on the use of radiation therapy to treat cancer. Since the patient has decided not to continue with treatment, this specialty would not be the most appropriate recommendation in this situation.
B.Hospice care is the most appropriate recommendation for a patient with a terminal diagnosis who has chosen to stop curative treatments. This specialty focuses on comfort, pain management, and emotional support for patients with a life expectancy of six months or less. It provides a multidisciplinary team to assist the patient and family during the end-of-life process.
C. Psychiatry may be helpful if the patient is experiencing significant emotional or psychological distress, but it is not the primary specialty needed for a terminal cancer patient who is opting for comfort-focused care.
D.Surgical oncology involves the physical removal of cancerous tumors through operative procedures. Because the patient has decided not to continue with cancer treatment, surgery—which is an invasive form of treatment—is no longer an objective. A surgical consult would not align with the patient’s goal of comfort and the cessation of aggressive medical interventions.
Correct Answer is C
Explanation
A. The subdivision of pancreatic tumors into endocrine versus exocrine reflects their cell of origin (islet cells versus ductal cells) rather than conveying information about how the cancer behaves in situ or its propensity for local invasion and metastasis
B. Unlike some other cancers (e.g., colorectal cancer), pancreatic cancer does not typically develop from polyps. Most cases of pancreatic cancer develop from the pancreatic ductal cells (the cells lining the ducts of the pancreas), and the disease is typically aggressive and diagnosed at a later stage.
C. Because the pancreas lies deep in the retroperitoneum directly adjacent to major vessels like the superior mesenteric artery and portal vein, tumors often extend into these structures early, contributing to the high rate of advanced disease at diagnosis
D. Pancreatic cancer is not distinguished based on layers. Instead, it is generally categorized based on the type of cells it affects (e.g., ductal cells in exocrine pancreatic cancer). The staging of pancreatic cancer is based on factors like tumor size, lymph node involvement, and metastasis, rather than the layers of the pancreas.
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