QUESTIONS WITH DETAILED SOLUTIONS
◉What is the appropriate gauge size for an intravenous (IV)
catheter used for blood transfusions?
A. 20-gauge
B. 18-gauge
C. 22-gauge
D. 24-gauge. Answer: Correct Answer: B
Rationale: An 18-gauge catheter is recommended for blood
transfusions to ensure a rapid and safe flow of blood.
◉During a blood transfusion, the nurse notices the patient is
becoming restless and anxious. What should the nurse do first?
A. Stop the transfusion immediately
B. Increase the infusion rate
C. Document the findings
D. Administer oxygen. Answer: Correct Answer: A
,Rationale: Stopping the transfusion immediately is essential to
prevent a potentially serious transfusion reaction.
◉A patient receiving a blood transfusion suddenly develops a fever
and chills. What type of reaction is most likely occurring?
A. Allergic reaction
B. Febrile non-hemolytic reaction
C. Hemolytic reaction
D. Transfusion-related acute lung injury (TRALI). Answer: Correct
Answer: B
Rationale: Fever and chills are common signs of a febrile non-
hemolytic reaction, which can occur during a transfusion.
◉After the administration of a blood transfusion, how long should
the nurse continue to monitor the patient's vital signs?
A. Every 5 minutes for the first hour
B. Every 15 minutes for the first hour
C. Every 30 minutes for the first hour
D. Every hour until the transfusion is complete. Answer: Correct
Answer: B
Rationale: Monitoring vital signs every 15 minutes for the first hour
helps identify any immediate reactions to the transfusion.
,◉The nurse is educating a patient about the risks associated with
blood transfusions. Which of the following should be included in the
teaching?
A. Blood transfusions are always safe
B. There is a risk of allergic reactions and infections
C. Transfusions can be done without consent
D. The patient will not feel any side effects. Answer: Correct Answer:
B
Rationale: Educating the patient about the risks, including allergic
reactions and infections, is crucial for informed consent.
◉During a blood transfusion, the nurse notices that the infusion is
running very slowly. What is the first action the nurse should take?
A. Check for kinks in the IV tubing
B. Increase the IV pump rate
C. Change the blood product
D. Notify the healthcare provider. Answer: Correct Answer: A
Rationale: Checking for kinks or obstructions in the IV tubing is the
first step in addressing a slow infusion rate.
, ◉What is the appropriate time frame for administering a blood
transfusion once the blood is received from the blood bank?
A. Within 2 hours
B. Within 6 hours
C. Within 12 hours
D. Within 4 hours. Answer: Correct Answer: D
Rationale: Blood transfusions should be administered within 4
hours of receipt to minimize the risk of bacterial growth and
transfusion reactions.
◉A patient receiving a blood transfusion suddenly experiences back
pain. What is the most appropriate nursing action?
A. Administer analgesics
B. Stop the transfusion and assess the patient
C. Increase the IV rate
D. Call the healthcare provider. Answer: Correct Answer: B
Rationale: Stopping the transfusion and assessing the patient is
crucial to determine if a transfusion reaction is occurring.
◉After a blood transfusion, what should the nurse document in the
patient's medical record?