Question: Nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. Approximately how long will the nurse need to stay with the client to ensure that a transfusion reaction is not occurring?
1. 5 minutes
2. 15 minutes
3. 40 minutes
4. 45 minutes
Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other assigned clients during this time. Therefore options 1, 3, and 4 are incorrect time frames.
Test-Taking Strategy: Use knowledge regarding blood transfusion procedures to answer this question. Remember that the client must be monitored directly for the first 15 minutes of the transfusion. Review the nursing responsibilities involved in beginning a blood transfusion if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiology Integrity
Integrated Process: Nursing Process-Planning
Content Area: Fundamental Skills-Medications/Blood & IV Therapy
References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care (6th ed., p. 918). St. Louis: Saunders.
This week’s NCLEX exam practice question came from:
Silvestri: Saunders Comprehensive Review for the NCLEX-RN Examination, 5th edition Chapter 15, pg 173, question123
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