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Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply

Hang a bag of 0.9% normal saline with 5% dextrose at the bedside (D5%NS)

Verify the client's name and blood type with a second nurse

Infuse the unit of blood within 4 hours.

Obtain baseline vital signs prior to starting the transfusion

Continuously monitor the client during the first 15 minutes of the transfusion

Insert an 18-gauge intravenous catheter

Insert a 22-gauge intravenous catheter

Answer and Explanation

Correct Answer : B,C,D,E,F

A. Hanging a bag of 0.9% normal saline with 5% dextrose (D5%NS) is incorrect; only normal saline (0.9% NS) should be used to prime the blood transfusion line to avoid hemolysis.

B. Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions and ensure the correct blood product is given.

C. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth in the blood product.

D. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition and monitor for any changes during the transfusion.

E. Continuously monitoring the client during the first 15 minutes of the transfusion is vital for detecting any signs of a transfusion reaction promptly.

F. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions as it provides a sufficient lumen to accommodate the blood flow.

G. Inserting a 22-gauge intravenous catheter is acceptable for some transfusions, but an 18-gauge is preferred for larger blood products.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["A","E","F"]

Explanation

A. Ensure comfortable seating at eye level for the client and nurse: Establishes a non-intimidating environment, helping the client feel more at ease.

B. Provide seating for the client so that the client faces a strong light: Incorrect; this may cause discomfort and make the client feel scrutinized.

C. Ensure that the distance between the client and nurse is at least 7 ft: Too great a distance for effective communication; ideal distance is 3-4 feet.

D. Place a chair for the client across from the nurse's desk: Creates a formal, potentially intimidating setting, discouraging openness.

E. Set the room temperature at a comfortable level: Ensures physical comfort, aiding in client relaxation and openness.

F. Remove distracting objects from the interviewing area: Minimizes potential distractions, keeping the client focused and the environment conducive to communication.

A. "I have sharp pain in my lower back." B. "I am coughing a lot more now." C. "I hear ringing in my ears." D. "I feel needles poking in my feet."

Correct Answer is A

Explanation

A. Sharp pain in the lower back is a classic symptom of an acute hemolytic reaction, which can occur due to incompatible blood transfusions.

B. Coughing more could indicate a transfusion-related acute lung injury (TRALI) but is not a typical sign of an acute hemolytic reaction.

C. Ringing in the ears can occur with other conditions but is not a common sign of an acute hemolytic reaction.

D. Feeling needles poking in the feet is vague and not specifically associated with acute hemolytic reactions, which are characterized by more severe systemic symptoms.

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Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is setting up the physical environment for an interview with a client and plans to obtain subjective data regarding the client's health. Which interventions are appropriate? Select three options that apply.

Correct Answer is ["A","E","F"]

Explanation

A nurse is assessing a client who is receiving a unit of packed red blood cells. Which client statement suggests manifestation of an acute hemolytic reaction?

Correct Answer is A

Explanation

A nurse is preparing to transfuse a unit of packed red blood cells for a client with severe anemia. The nurse should identify that which of the following interventions will help prevent an acute hemolytic reaction?

A nurse is planning care for a client with pernicious anemia. Which intervention should the nurse plan to implement?

A nurse is providing education to a client with human immunodeficiency virus (HIV) who is experiencing wasting syndrome. Which of these suggestions is most appropriate?

Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply

A nurse is caring for a client with Acquired Immunodeficiency Syndrome (AIDS). Which client statement demonstrates a need for further education?

A nurse is caring for a client who is coming to the clinic for human immunodeficiency virus (HIV) testing. The patient's enzyme-linked immunosorbent assay (ELISA) results are positive. Which test will be used to confirm the diagnosis of HIV?

A nurse is presenting a community-based program about HIV and AIDS. A client asks the nurse to describe the initial symptoms experienced with HIV infection. Which manifestation(s) should the nurse include?

A nurse is providing teaching to a client who has vitamin B12 deficiency. Which of the following foods should the nurse instruct the client to consume? Select all that apply.