Problem 24 - Cliffs Test Prep NCLEX-RN

Question

A patient with blood type AB, Rh factor positive needs a blood transfusion. The Transfusion Service (blood bank) sends type O, Rh factor negative blood to the unit for the nurse to infuse into this patient. The nurse knows that: 1\. this donor blood is incompatible with the patient’s blood. 2\. premedicating the patient with diphenhydramine hydrochloride (Benadryl) and acetaminophen (Tylenol) will prevent any transfusion reactions or side effects. 3\. this is a compatible match. 4\. the patient is at minimal risk receiving this product since it is the first time he has been transfused with type O, Rh negative blood.

Step-by-Step Solution

Answer

The correct answer is 3: this is a compatible match.

Step 1: Understanding Blood Types and Compatibility

Blood type AB can accept blood from all blood types since it is a universal recipient, meaning anyone with this blood type can receive A, B, AB, or O type blood. Rh factor positive indicates that the patient can receive both Rh positive and Rh negative blood. Therefore, type O, Rh factor negative blood is compatible with any blood type, including AB.

Step 2: Compatibility Analysis

Type O blood is known as the universal donor due to its lack of A and B antigens on red cells. For the Rh factor, negative means it can be safely transfused into individuals with a positive Rh factor without triggering an immune response. Thus, type O, Rh negative blood is universally compatible and safe for use in patients with type AB, Rh positive blood.

Step 3: Evaluating Statements

Given the blood type compatibility, statement 1 is incorrect because the blood is compatible, statements 2 and 4 do not provide relevant practices or truths as preventive measures, leaving statement 3 as the most accurate.

Key Concepts

Blood Type Compatibility

Understanding blood type compatibility is crucial in nursing education, especially when it comes to blood transfusions. Humans have four primary blood types: A, B, AB, and O. These are determined by the presence or absence of specific antigens on the surface of red blood cells.

• Type A has A antigens.
• Type B has B antigens.
• Type AB has both antigens and is considered the universal recipient.
• Type O has no antigens, which is why it is called the universal donor.

If a patient with Type AB blood needs a transfusion, they can receive red blood cells from any blood type due to having both A and B antigens. Moreover, Type O blood is compatible with all other blood types because it doesn't carry antigens that can induce an immune response. Therefore, understanding these compatibilities helps ensure safe and effective blood transfusions.

Transfusion Reactions

Transfusion reactions are adverse events that can occur during or after a blood transfusion, resulting from incompatibility or immune responses. Nurses must be vigilant about signs of reactions to mitigate risks promptly. Transfusion reactions can be mild, such as itching or fever, or severe, leading to life-threatening conditions like anaphylactic shock.
Here are common symptoms of transfusion reactions:

• Fever and chills
• Rash or hives
• Shortness of breath
• Lower back pain
• Hypotension or hypertension

Nurses should be aware that premedicating with antihistamines and antipyretics, such as diphenhydramine hydrochloride and acetaminophen, might help in some cases but doesn’t eliminate the risk of an allergic reaction. Monitoring patients closely during transfusions and having emergency protocols can greatly reduce potential complications.

Rh Factor

The Rh factor is a protein on the surface of red blood cells that can be either present (Rh positive) or absent (Rh negative). It plays a critical role in blood transfusion compatibility. In blood transfusions, Rh compatibility is essential to avoid complications. If an Rh-negative person receives Rh-positive blood, their immune system may treat the Rh factor as an invader and mount a response against it. This is not an issue for Rh-positive individuals, who can safely receive both Rh-positive and Rh-negative blood.
For example, individuals with blood type AB, Rh factor positive, like the patient in the exercise, can safely receive blood from any Rh factor status. This flexibility makes them ideal recipients in emergency situations when blood type matching is crucial. Understanding the implications of Rh factor helps ensure safe transfusion practices, minimizing risks of hemolytic reactions and subsequent patient complications.