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Exam NCLEX-RN topic 4 question 171 discussion

Actual exam question from Test Prep's NCLEX-RN
Question #: 171
Topic #: 4
[All NCLEX-RN Questions]

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:

  • A. Take a baseline set of vital signs
  • B. Hang Ringer’s lactate as the companion fluid
  • C. Use microdrip tubing for the blood administration
  • D. Have the registered nurse in charge assume responsibility for verifying the client and blood product information
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Suggested Answer: A 🗳️
(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 Ringers lactate can cause clotting. (C) Only a blood administration set should be used.
A microdrip tube would cause lysis of the red blood cells. (D) Proper identification of the recipient and the blood product must be validated by at least two people.
by [deleted] at March 10, 2025, 6:53 a.m.

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