Evolve HESI Practice Exam

Which intervention is most crucial for a nurse when a client with acute hemorrhagic anemia is to receive four units of packed RBCs?

1. Prep the infusion equipment

2. Ensure the accuracy of the blood type match

3. Monitor vital signs during transfusion

4. Administer medications as prescribed

The correct answer is: Ensure the accuracy of the blood type match

Ensuring the accuracy of the blood type match is pivotal when administering blood transfusions, particularly in a case of acute hemorrhagic anemia where the client may already be compromised. This step is essential to prevent severe transfusion reactions that can arise from mismatched blood types. The correct matching of blood types helps avoid hemolytic reactions, which can lead to serious complications such as kidney failure, shock, or even death. In acute situations where rapid transfusion of packed RBCs is required, establishing compatibility is critical because any discrepancy in the blood type could exacerbate the client’s condition significantly, causing further hemolysis and additional complications. While preparing the infusion equipment, monitoring vital signs during the transfusion, and administering prescribed medications are also important nursing responsibilities, they are secondary to ensuring the blood type match. If the blood is not accurately matched, even the best-prepared equipment or diligent monitoring will not prevent the potential life-threatening consequences of a mismatched transfusion.