Evolve HESI Practice Exam

What is the primary goal when monitoring a client receiving packed RBCs?

1. Maintain fluid balance

2. Prevent transfusion reactions

3. Ensure nutritional status

4. Administer medication on time

The correct answer is: Prevent transfusion reactions

The primary goal when monitoring a client receiving packed red blood cells (RBCs) is to prevent transfusion reactions. This is crucial because transfusion reactions can lead to serious and sometimes life-threatening complications, such as hemolysis, allergic reactions, febrile reactions, or transfusion-related acute lung injury (TRALI). Monitoring includes assessing vital signs before, during, and after the transfusion to catch any adverse reactions early. Additionally, the nurse should be vigilant for any signs and symptoms of a reaction, such as fever, chills, itching, or respiratory distress, allowing for prompt intervention. While maintaining fluid balance, ensuring nutritional status, and administering medications on time are all important aspects of patient care, they do not have the same level of immediacy in context as preventing transfusion reactions. The priority in a transfusion setting is to ensure the safety of the patient by minimizing the risk of complications associated with blood transfusions.