Exam NCLEX-RN topic 4 question 170 discussion

Actual exam question from Test Prep's NCLEX-RN

Question #: 170
Topic #: 4

A client has been admitted to the nursing unit with the diagnosis of severe anemia. She is slightly short of breath, has episodes of dizziness, and complains her heart sometimes feels like it will "beat out of her chest." The physician has ordered her to receive 2 U of packed red blood cells. The most important nursing action to be taken is:

A. Starting an 18-gauge IV infusion
B. Having the consent form on the chart
C. Administering the correct blood product to the correctclient
D. Transfusing the blood in a 2-hour time frame

Show Suggested Answer

Suggested Answer: C 🗳️
(A) An 18-gauge IV is an appropriate size for administering blood; however, client safety demands that the right blood product must be administered. (B) The consent form is legally necessary to be on the chart, but client safety is maintained by giving the correct blood component to the correct client. (C) Administering the correct blood product to the correct client will maintain physiological safety and minimize transfusion reactions. (D) The blood administration should take place over the ordered time frame designated by the physician.

by [deleted] at March 10, 2025, 6:53 a.m.

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