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Blood Administration NCLEX and Answers Version 2025/2026 Correct &

A client with heart failure is receiving a blood transfusion. What should the nurse monitor for?

• Hypokalemia

✔✔ B. Fluid overload

• Hypothermia
• Thrombocytopenia

What should the nurse do if a unit of blood is not used within 30 minutes of removal from the blood bank?✔✔ A. Return it to the blood bank

• Place it in the medication fridge
• Label it for later use
• Warm it for 10 minutes

Which of the following is a priority nursing action during the first 15 minutes of a transfusion?

• Document the intake and output 1 / 3

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✔✔ B. Stay with the client and monitor for reactions

• Check electrolyte levels
• Prepare the next dose of medication

Which IV gauge is most appropriate for administering packed red blood cells in an adult?

• 24 gauge

✔✔ B. 20 gauge

• 25 gauge
• 16 gauge butterfly

What is the correct action when a transfusion reaction is suspected?✔✔ A. Stop the transfusion and maintain the IV line with saline

• Call radiology for a chest x-ray
• Flush the line with dextrose
• Recheck the blood bag label

A client receiving a transfusion reports itching and has a mild rash. What is the nurse’s first action? 2 / 3

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✔✔ A. Stop the transfusion

• Reassure the client
• Apply lotion
• Continue and monitor closely

Why must blood products be infused with filtered tubing?

• To prevent electrolyte imbalance
• To regulate flow rate

✔✔ C. To remove clots and debris

• To prevent infection

Which blood product is indicated for a client with thrombocytopenia?

• Fresh frozen plasma

✔✔ B. Platelets

• Packed red blood cells
• Albumin

When documenting a completed transfusion, what information should be included?

• / 3