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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…

Physiological Integrity: Reduction of Risk Potential

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)
  • A
    89% (24)
  • C
    4% (1)
  • D
    7% (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

Topics

#blood transfusion#baseline vital signs#pre-transfusion assessment#packed red blood cells

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