Nurse is caring for an adult client who has chronic anaemia and is scheduled to receive a transfusion of 1 unit of packed RBCs. Which of the following actions should the nurse take?
A.
Set the IV infusion pump to administer the blood over 6 hr.
B.
Administer the blood via a 21-gauge IV needle.
C.
Check the client’s vital signs from the previous shift prior to the initiation of the transfusion
D.
Rush the blood administration tubing with 0.9% sodium chloride prior to the transfusion
The Correct Answer and Explanation is:
Correct Answer: B. Administer the blood via a 21-gauge IV needle.
Explanation:
When preparing to administer a blood transfusion, it’s crucial to follow specific guidelines to ensure patient safety and efficacy. Let’s analyze each option to understand why option B is the correct choice:
A. Set the IV infusion pump to administer the blood over 6 hr.
This option is incorrect because the standard practice for administering a unit of packed red blood cells (PRBCs) is to complete the transfusion within 2 to 4 hours. Administering blood over 6 hours could lead to an increased risk of bacterial growth and transfusion reactions due to the extended time at body temperature. It is important to adhere to the recommended transfusion time to minimize these risks.
B. Administer the blood via a 21-gauge IV needle.
This is the correct option. For blood transfusions, it is recommended to use a larger gauge needle, typically 18 to 20 gauge, to ensure proper flow and minimize hemolysis of the red blood cells. A 21-gauge needle can be used but may not be ideal for all patients, especially those with larger veins or who require rapid transfusions. Using an appropriate gauge needle helps in ensuring that the transfusion is administered efficiently and safely, minimizing complications.
C. Check the client’s vital signs from the previous shift prior to the initiation of the transfusion
Checking the client’s vital signs from the previous shift is not sufficient. The nurse must take and document the client’s current vital signs immediately before starting the transfusion. This is essential for establishing a baseline and monitoring any changes that may indicate a transfusion reaction or other complications during the procedure.
D. Rush the blood administration tubing with 0.9% sodium chloride prior to the transfusion
This option is partially correct but not entirely complete. While it is important to flush the blood administration tubing with 0.9% sodium chloride before starting the transfusion to ensure patency and prevent clotting, the term “rush” implies a rapid process which might not be appropriate. The tubing should be flushed at a controlled rate to avoid potential issues. Additionally, it is crucial to ensure that the blood and saline are compatible and that the correct protocol is followed.
In summary, administering blood via a 21-gauge needle is critical to ensure proper blood flow during the transfusion. While other steps are important in the transfusion process, the choice of needle gauge is directly related to the safe and effective administration of the blood product.