Difficulty: Medium
Average Score: 66%
Simulated
Passage / Scenario
Provider Prescriptions 1230:0.9% sodium chloride 500 mL bolus then 100 mL/hr.
Type and cross match for 2 units of packed RBCs.
Repeat WBC, hemoglobin, hematocrit STAT.
Delay endoscopy.
2L/min O, via nasal cannula,
1330:
2 units packed RBCs IV over 4 hr.
Repeat WBC, hemoglobin, hematocrit at transfusion completion
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
Correct answer
B
Rationale
[0, 1, 0, 0]
The correct answer is Stay with the client for the first 15 min of the transfusion. This action is indicated to monitor for adverse reactions such as fever, chills, or signs of hemolysis. Documenting the blood product transfusion (A) is important but not a priority during the initial phase. Titrating the infusion rate (C) and obtaining the blood product (D) are essential, but staying with the client for monitoring takes precedence. Starting an IV bolus (E) is not related to blood transfusion monitoring.
The correct answer is Stay with the client for the first 15 min of the transfusion. This action is indicated to monitor for adverse reactions such as fever, chills, or signs of hemolysis. Documenting the blood product transfusion (A) is important but not a priority during the initial phase. Titrating the infusion rate (C) and obtaining the blood product (D) are essential, but staying with the client for monitoring takes precedence. Starting an IV bolus (E) is not related to blood transfusion monitoring.