The nurse reviews the entries in the medical record.
Exhibits
The nurse is ready to begin the blood transfusion. For each potential nursing action, click to specify if the action is indicated or not indicated for the client.
A.
Stay with the client for the first 15 min of the transfusion.
B.
Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg.
C.
Document the blood product transfusion in the client’s medical record.
D.
Obtain the first unit of packed RBCs from the blood bank.
E.
Start an IV bolus of lactated Ringer’s solution.
The Correct Answer and Explanation is :
When preparing to administer a blood transfusion, several key nursing actions must be taken to ensure patient safety and the effective administration of the blood product. Let’s review each action listed:
A. Stay with the client for the first 15 minutes of the transfusion.
Indicated
It is crucial for the nurse to stay with the client for the first 15 minutes of the transfusion. This period is critical because it is when most transfusion reactions are likely to occur. Early monitoring allows the nurse to promptly identify any signs of an adverse reaction, such as fever, chills, rash, or difficulty breathing, and to take immediate action if necessary. Close observation helps ensure that the blood is being administered properly and that the client is tolerating the transfusion well.
B. Titrate the rate of infusion to maintain the client’s blood pressure at least 90/60 mm Hg.
Not Indicated
Titrating the infusion rate based on blood pressure is not a standard practice for blood transfusions. The rate of blood transfusion is typically based on the client’s clinical condition, the type of blood product, and the blood bank’s instructions. Blood transfusions are usually given at a specific rate to prevent complications such as fluid overload, and not specifically to maintain a certain blood pressure. Monitoring vital signs, including blood pressure, during the transfusion is important, but the infusion rate should follow the protocol rather than being adjusted solely to manage blood pressure.
C. Document the blood product transfusion in the client’s medical record.
Indicated
Documentation of the blood product transfusion in the client’s medical record is essential. This documentation should include details such as the type of blood product transfused, the date and time of the transfusion, the volume of blood administered, and any reactions or complications observed. Accurate documentation provides a record of the transfusion process, helps track the client’s response, and ensures continuity of care.
D. Obtain the first unit of packed RBCs from the blood bank.
Not Indicated
Obtaining blood products from the blood bank is typically done by a designated personnel, such as a blood bank technician or a hospital transporter, rather than the nurse. The nurse’s role usually involves verifying the blood product upon receipt and ensuring it matches the client’s blood type and compatibility before administration.
E. Start an IV bolus of lactated Ringer’s solution.
Indicated
Starting an IV bolus of Lactated Ringer’s solution or normal saline is often indicated to ensure proper hydration and to maintain venous access before beginning the blood transfusion. It can help reduce the risk of transfusion reactions and complications related to vein irritation. The use of an appropriate intravenous fluid before and sometimes during the transfusion can help in managing blood flow and maintaining adequate venous access.
In summary, actions A, C, and E are indicated, while B and D are not typically indicated. Each action plays a role in ensuring the safe and effective administration of a blood transfusion.