Question

A client with iron deficiency anemia has been noncompliant with iron medications. He is admitted requiring a blood transfusion due to severe anemia. The nurse starts the transfusion at 1300 and realizes it must be completed by: A. 1400 B. 1500 C. 1600 D. 1700

Short answer

Answer: D. 1700

Step-by-step solution

Add 4 hours to the starting time

First, we need to add 4 hours to the starting time (1300) to determine the time at which the transfusion will be completed. 1300 + 4 hours = 1700 The transfusion will be completed at 1700 hours.

Choose the correct answer

Now, among the given options, choose the time that matches the time calculated in Step 1. A. 1400 B. 1500 C. 1600 D. 1700 The correct answer is D. 1700.

Key concepts

Iron Deficiency Anemia

Iron deficiency anemia is a common type of anemia that occurs when the body doesn't have enough iron to produce adequate hemoglobin, which is the molecule in red blood cells that carries oxygen. The condition can lead to symptoms like fatigue, weakness, and shortness of breath. In severe cases, when oral supplementation fails or the patient is noncompliant with medications, as illustrated in the exercise, a blood transfusion may be necessary to quickly increase red blood cell counts.

Understanding the causes and treatment for iron deficiency anemia is essential for nursing care. It is important for a nurse to educate patients about the importance of iron-rich diets and adherence to iron supplementation to prevent the condition from worsening. Common sources of dietary iron include red meat, beans, and fortified cereals. In the case of a noncompliant patient requiring a transfusion, monitoring for complications such as transfusion reactions is a critical clinical skill.

NCLEX-RN Exam Preparation

Preparing for the NCLEX-RN exam, a standardized test that each nurse must pass to obtain licensure, involves mastering a wide array of knowledge, including the management of iron deficiency anemia and the logistics of blood transfusion. Key concepts to focus on for exam preparation include pathophysiology, pharmacology, and patient care management.

When reviewing questions related to blood transfusions, such as the exercise presented, candidates should understand the rationale behind transfusion time limits and the importance of cross-checking times in practice to ensure patient safety. Utilizing NCLEX prep materials that offer step-by-step solutions not only help in memorizing facts but also in developing critical thinking skills vital for a successful nursing career.

Nursing Clinical Skills

Blood Transfusion Protocols

When administering a blood transfusion, it is imperative for a nurse to possess a solid foundation of clinical skills. This encompasses verifying patient identity, confirming blood type compatibility, and following the protocol for the rate and duration of the transfusion. Blood transfusions are usually recommended to be completed within 4 hours to reduce the risk of bacterial growth in the blood product.

Monitoring and Assessment

Throughout the transfusion, nurses must diligently monitor the patient for signs of adverse reactions. Vital signs should be checked according to the facility's policy, often before, during, and after the transfusion. Nurses should also be well-versed in the immediate steps to take if a transfusion reaction is suspected, highlighting the importance of timely intervention in patient outcomes.