NCLEX-RN · Question #434
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
The correct answer is A. Take a baseline set of vital signs. (A) A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. (B) The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting…
Question
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
Options
- ATake a baseline set of vital signs
- BHang Ringer's lactate as the companion fluid
- CUse microdrip tubing for the blood administration
- DHave the registered nurse in charge assume responsibility for verifying the client and blood
How the community answered
(27 responses)- A89% (24)
- C4% (1)
- D7% (2)
Explanation
(A) A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. (B) The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. (C) Only a blood administration set should be used. A microdrip tube would cause lysis of the red (D) Proper identification of the recipient and the blood product must be validated by at least two
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