Author Question: The nurse administering a blood transfusion is aware that which of the following is the most ... (Read 50 times)

DelorasTo · **on:** Jun 28, 2018

The nurse administering a blood transfusion is aware that which of the following is the most important nursing action to prevent a transfusion reaction?

A.
Checking the provider's orders for transfusion
B.
Identifying the patient with two unique identifiers
C.
Monitoring vital signs per protocol
D.
Staying with patient for the first 15 minutes

Question 2

In preparing a patient to receive an autologous bone marrow transplantation, which action by the nurse is best?

A.
Ensure HLA typing has been done.
B.
Limit visitors to one per shift.
C.
Place the child in protective isolation.
D.
Teach about long-term complications.

pocatato · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: B
All actions are important when administering blood products. However, to prevent a transfusion reaction, accurate patient identification using two unique identifiers (and two nurses) is critical. The nurse should check the orders prior to proceeding. Staying with the patient and monitoring vital signs will not help prevent a reaction but will help identify one quickly.

Answer to Question 2

ANS: C
In preparation for a bone marrow transplant, patients are given near lethal doses of chemotherapy and/or radiation in order to completely destroy their own bone marrow. This child will need protective isolation. HLA typing does not need to be done, as the source of the bone marrow is the child herself. Visitors do not need to be limited so severely. Teaching about complications is important, but does not take priority over protecting the child.