img-download-app
img-download-app

A physician orders a blood transfusion for an anemic patient. Before transfusing the patient, the nurse should:

Explanation

•To ensure compatibility between the patient and the donor blood, the patient's blood needs to be screened for typing and crossmatching.

•Typing and crossmatching is required before blood will be released for transfusion, so this should be done first. Having a second RN verify cross match and identification is generally standard for most hospitals.

•Obtaining baseline vital signs is best practice for monitoring patient response to the transfusion. Patients generally do not know their hospital number, but you should verify their name and birthday.

•Normal saline is the only fluid compatible with blood transfusions.

•The recipient's blood type is determined (i.e., their ABO type and RhD status) and a crossmatch is done. To perform a crossmatch, a small amount of the recipient's serum is mixed with a small amount of the donor RBCs. If the transfusion would be incompatible, the donor RBCs will be agglutinated by antibodies in the recipient's serum when examined by microscope.

•Always verify the order, conduct and document a thorough physical assessment of the patient (including vital signs) to help identify later changes. Baseline vitals including temperature and respirations will be taken just prior to administration of blood product and every 15–30 minutes during administration. Assess the IV access site for patency; catheter should ideally be size 18 gauge or larger. Confirm that informed consent was given and teach the patient about the signs and symptoms of a reaction.

•Before starting the transfusion, two RNs (this policy may vary) must confirm the following on the blood, paperwork, and the blood ID band at the bedside: blood ABO and Rh type, unit expiration date, blood unit unique identifier (or barcode), and patient's name and DOB confirmed with the patient ID band.

•Begin the transfusion slowly, at a rate of 2 mL/minute for the first 15 minutes (100 mL/hour). Stay with the patient for the first 15 minutes and assess vital signs at 15 minutes and again at 30 minutes. Most severe reactions occur in the first 15 minutes or 50 mL of the transfusion. Watch for pain near the insertion site, backache, fever, chills, itching, hives, dyspnea, or unusual complaints from the patient. From the time a unit of blood is spiked, the infusion should take a maximum of 4 hours. Each unit of plasma or platelets should be administered over 30-60 minutes maximum.

•If a reaction is suspected, stop the blood immediately, replace the tubing, and run 0.9% normal saline. Report this to the health care provider AND the blood bank immediately. The entire unit with tubing still connected is usually retrieved by the blood bank.

Visit our website for other NCLEX topics now!
Related questions

A nurse working in a bariatric clinic is preparing educational materials for a presentation to a group of clients who will be undergoing gastric bypass surgery. According to Healthy People 2020, the nurse should include which of the following guidelines to assist this patient population?

A nurse is documenting the intake and output of her patients. The nurse would consider which of the following insensible fluid loss?

To help a mother anticipate the safety needs of her nine-year-old son who is learning to ride a bicycle, the nurse should teach that:

While preparing to administer a subcutaneous injection, the nurse disinfects the injection site and waits for how long before administering the injection?

When administering a heparin injection, the nurse minimizes pain by choosing which insertion site?

A nurse noticed a nursing assistant entering the room of a patient with tuberculosis. Which action by the nursing assistant demonstrates a need for education on airborne precautions?

A nurse has been teaching a 16-year-old boy about health promotion. Which of the following statements made by the boy indicates effective education?

Another RN has called in sick, leaving 10 pediatric cancer patients to be cared for by one RN and 3 nursing assistants. What should the nurse do?

A patient who will undergo plastic surgery tells the nurse she is embarrassed about the surgery and asks the nurse not to tell anyone. How should the nurse respond?

After taking shift report from the day nurse, a senior nurse on the unit comes to you and says, "Double check all your orders and MARs before you get started. The nurse you followed is a total screw up." How should you handle this situation?

Which of the following should the nurse delegate to the licensed practical nurse (LPN)?

A living will includes which of the following?

Three nurses are discussing a patient's manic symptoms in the cafeteria. The patient's daughter overhears details that she was unaware of and begins to tell the rest of the family. The nurses are guilty of which of the following?

The nurse is caring for a patient with an infiltrated IV from normal saline. The nurse first stops the infusion. What other action demonstrates an appropriate response? 

A patient's sister is in nursing school and requests to see the patient's medical record. She states that it would be a great learning opportunity. What should the nurse do?

When preparing the morning medications for Mr. Smith, the nurse notices digoxin in his med drawer. He does not have an order for digoxin on his medication administration record. What should the nurse do?

Before administering medications, the nurse should assess the kidney and liver function of which of the following populations?

The nurse is teaching a mother on safety measures when caring for a 19-month-old child. Which of the following statements by the mother indicates that the teaching provided by the nurse regarding safety has been effective?

A nurse on the cardiac telemetry floor is preparing to admit a new patient with complaints of chest pain and shortness of breath. The nurse may delegate to the certified nursing assistant (CNA) which one of the following? 

Before administering IV medication into an unused IV catheter, the nurse should flush the IV line with:

Which of the following demonstrates appropriate nursing documentation?

A patient with a nasogastric (NG) tube has medications ordered. The nurse recognizes that which of the following medications can be administered through the NG tube:

Of the following nursing diagnoses, which is most appropriate for the care plan of a patient having trouble remembering to take all of his medications?

A patient is admitted to the hospital with an INR of 3.9, history of a GI bleed, and osteomyelitis. The patient is complaining of bone pain, so the nurse prepares to administer morphine. Which route should be avoided?