Fundamentals of Nursing Q 368
Which nursing intervention takes the highest priority when caring for a newly admitted client who’s receiving a blood transfusion?
A. Warming the blood prior to transfusion.
B. Informing the client that the transfusion usually takes 4 to 6 hours.
C. Documenting blood administration in the client chart.
D. Instructing the client to report any itching, chest pain, or dyspnea.
Correct Answer: D. Instructing the client to report any itching, headache, or dyspnea.
This will help the nurse take immediate action in case a reaction happens during a transfusion. There are multiple complications of blood transfusions, including infections, hemolytic reactions, allergic reactions, transfusion-related lung injury (TRALI), transfusion-associated circulatory overload, and electrolyte imbalance.
Option A: There is no evidence that warming blood is beneficial to the patient when transfusion is slow. At transfusion rates of greater than 100 mL/minute, cold blood may be a contributing factor in cardiac arrest. However, keeping the patient warm is probably more important than warming the blood.
Option B: Transfusion of a unit of blood should be completed within a maximum period of four hours after removal from the blood fridge: discard the unit if this period is exceeded. If blood has been out of the blood bank refrigerator for more than 30 minutes and is not transfused, then the unit must be returned to the laboratory, where it will be disposed of.
Option C: Documentation related to transfusion therapy should include verification of the prescribed blood product and blood product compatibility; verification of appropriate clinical indication for the transfusion; the date and time of transfusion, type of blood product administered, in addition to the volume, infusion rate, and time of initiation and completion of transfusion; any medication administered, including premedication (if I.V. drugs are required during transfusion, another I.V. site is required); the patient’s clinical status throughout the transfusion therapy, including patient assessment data such as vital signs and lung sounds; the patient’s response to therapy including any complications or adverse reactions, treatment required, and response to that treatment; and the amount of blood transfused and the return of the unused portion to the blood bank.