Question A client is receiving a blood transfusion, and the nurse observes the client experiencing chills, fever, and back pain. What is the priority action for the nurse?
A) Administering an antipyretic
B) Slowing down the blood transfusion rate
C) Discontinuing the transfusion
D) Notifying the healthcare provider
E) Documenting the findings and continuing the transfusion
Rationale: The client’s symptoms indicate a possible transfusion reaction. The priority action is to discontinue the transfusion immediately to prevent further complications. Notifying the healthcare provider and documenting findings are important, but the immediate action should be stopping the transfusion to ensure the client’s safety. Correct Answer: C) Discontinuing the transfusion
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Question A nurse is preparing to administer a blood transfusion to a client. The blood is ready, and the client’s identification has been verified. What additional information is essential before initiating the transfusion?
A) The client’s blood pressure
B) The client’s temperature
C) The client’s previous transfusion history
D) The client’s dietary preferences
E) The client’s family medical history
Rationale: Knowing the client’s previous transfusion history is crucial to identify any potential risks or complications, such as previous transfusion reactions or sensitivities. While monitoring blood pressure and temperature is important during the transfusion, understanding the client’s transfusion history takes precedence in ensuring the safe administration of blood products. Correct Answer: C) The client’s previous transfusion history
Question A nurse is preparing to administer a blood transfusion to a 65-year-old client with a history of chronic anemia. The client expresses anxiety and states, “I’m afraid of having a reaction.” What is the nurse’s best response?
A) Reassure the client that blood transfusions rarely cause reactions
B) Explain that reactions are common but usually not serious
C) Share personal experiences of successful blood transfusions with other patients
D) Acknowledge the client’s fear and discuss the safety measures in place
E) Proceed with the transfusion without addressing the client’s concern
Rationale: It’s crucial for the nurse to acknowledge and address the client’s anxiety. By discussing the safety measures in place, the nurse can help alleviate fears and build trust. Dismissing the client’s concerns or proceeding without addressing the fear may escalate anxiety and impact the overall experience of the transfusion. Correct Answer: D) Acknowledge the client’s fear and discuss the safety measures in place
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Understanding Blood Transfusion: NCLEX Priority Questions
Question A nurse is monitoring a client who just started receiving a blood transfusion. The client reports sudden chest pain and difficulty breathing. What is the nurse’s immediate action?
A) Administering oxygen
B) Slowing down the blood transfusion rate
C) Notifying the healthcare provider
D) Completing a thorough assessment
E) Discontinuing the blood transfusion
Rationale: The client’s symptoms suggest a potential transfusion reaction, and the immediate priority is to stop the transfusion to prevent further harm. While notifying the healthcare provider and completing a thorough assessment are important, discontinuing the transfusion is the immediate action to ensure patient safety. Correct Answer: E) Discontinuing the blood transfusion
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Understanding Blood Transfusion: NCLEX Delegation Questions
Question A nurse is preparing to administer a blood transfusion to a pediatric client. The prescribed blood product is not available in the pediatric size, and the nurse is considering using an adult-sized blood filter. What is the nurse’s best course of action?
A) Use the adult-sized blood filter as it will not affect the transfusion
B) Administer a reduced amount of the prescribed blood product
C) Consult with the healthcare provider for alternative options
D) Proceed with the transfusion without using any blood filter
E) Administer the blood product without any modifications
Rationale: Using an adult-sized blood filter for a pediatric client may lead to complications. It’s essential for the nurse to consult with the healthcare provider to explore alternative options or determine the safest course of action. Administering the blood product without modifications or using an inappropriate filter could compromise the child’s safety during the transfusion. Correct Answer: C) Consult with the healthcare provider for alternative options
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Understanding Blood Transfusion Reaction: Causes and Symptoms
Question A nurse is assessing a client before a scheduled blood transfusion. The client has a history of allergies and reports itching and hives after taking certain medications. What is the nurse’s priority action?
A) Proceed with the blood transfusion as scheduled
B) Administer an antihistamine before the transfusion
C) Notify the healthcare provider of the client’s history
D) Document the client’s allergy history in the chart
E) Request a different blood product for the transfusion
Rationale: The client’s history of allergies and symptoms of itching and hives indicate a potential allergic reaction. The nurse should notify the healthcare provider to assess the risk and determine the most appropriate course of action before proceeding with the blood transfusion. It is essential to ensure the client’s safety and prevent adverse reactions. Correct Answer: C) Notify the healthcare provider of the client’s history
NCLEX Practice Questions: Understanding Blood Transfusion Reaction Causes and Symptoms
Question A nurse is administering a blood transfusion to a client with a known history of transfusion reactions. During the transfusion, the client develops fever, chills, and lower back pain. What is the nurse’s immediate action?
A) Administering an antipyretic
B) Slowing down the blood transfusion rate
C) Discontinuing the transfusion
D) Notifying the healthcare provider
E) Documenting the findings and continuing the transfusion
Rationale: The client’s symptoms suggest a transfusion reaction, and the immediate action is to discontinue the transfusion to prevent further complications. Administering an antipyretic, notifying the healthcare provider, and documenting findings are important, but stopping the transfusion is the priority to ensure patient safety. Correct Answer: C) Discontinuing the transfusion
NCLEX Questions: Focus on Medications for Blood Transfusion
Question A nurse is preparing to administer a blood transfusion to a client. The client’s blood type is B-positive, and the ordered blood type is A-negative. What is the nurse’s appropriate action? A) Proceed with the transfusion, as the Rh factor is compatible
B) Request a different blood product for the transfusion
C) Administer the blood slowly to minimize potential reactions
D) Warm the blood to room temperature before administration
E) Filter the blood before initiating the transfusion
Rationale: Incompatible blood types can lead to severe reactions, including hemolysis. The nurse should request a different blood product with the correct blood type to ensure compatibility and prevent adverse effects. Administering the blood as is or trying to modify the process may compromise patient safety. Correct Answer: B) Request a different blood product for the transfusion
NCLEX Focus Exploring Blood Transfusion Reaction: Causes and Diagnosis
Question A nurse is preparing to administer a blood transfusion to a client with severe anemia. The client’s blood type is A-positive, and the ordered blood type is O-negative. The nurse notices that the blood bag contains clots. What should the nurse do?
A) Administer the blood slowly
B) Filter the blood before administration
C) Warm the blood to room temperature
D) Return the blood to the blood bank
E) Administer the blood as is
Rationale: Clots in the blood bag can lead to embolism and pose a serious risk to the client. Filtering the blood before administration helps remove clots and prevents complications such as pulmonary embolism. Administering the blood as is or returning it to the blood bank without addressing the clots could endanger the client’s safety. Correct Answer: B) Filter the blood before administration
NCLEX Review: Blood Transfusion Reaction Treatments
Question A nurse is educating a client about the potential risks associated with blood transfusions. The client asks about the transmission of infectious diseases through blood products. What is the nurse’s best response?
A) “Blood products are rigorously screened for infectious diseases, minimizing the risk.”
B) “There is a high risk of contracting infectious diseases through blood transfusions.”
C) “Infections from blood transfusions are common, but they are usually mild.”
D) “The risk of infectious diseases is minimal only if the blood comes from a family member.”
E) “There is no risk of infectious diseases if the blood products are administered slowly.”
Rationale: Providing accurate information is essential in addressing the client’s concerns. Blood products undergo thorough screening to minimize the risk of transmitting infectious diseases. This response reinforces the safety measures in place during blood transfusions, promoting client understanding and confidence in the procedure. Correct Answer: A) “Blood products are rigorously screened for infectious diseases, minimizing the risk.“
