Fundamentals of Nursing Q 376

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Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse Edward. Prior to the facilitation of the blood transfusion, nurse Paulo priority checks which of the following?

  

     A. Intake and output

     B. NPO standing order

     C. Vital signs

     D. Skin turgor

    

    

Correct Answer: C. Vital signs

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The nurse must assess the vital signs before and 15 minutes after the procedure so that any changes during the transfusion may indicate a transfusion reaction is happening. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes.

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Option A: Monitoring the intake and output during blood transfusion may be done, but not as often as necessary. Monitoring of intake helps the caregiver to ensure that the patient has a proper intake of fluid and other nutrients. Monitoring of output helps determine whether there is an adequate output of urine as well as normal defecation.

Option B: A patient on blood transfusion is not placed in an NPO standing order. Current nil per os (NPO) standards promote pre-operative fasting as an approach to reduce the volume and acidity of a patient’s stomach contents to reduce the risks of regurgitation and subsequent pulmonary aspiration. Pre-anesthesia fasting standards apply to any procedure where sedative medications reduce the protective airway reflex that under normal conditions prevent aspiration.

Option D: Physical findings suggestive of volume depletion include dry mucous membranes, decreased skin turgor, and low jugular venous distention. While the incidence of hypovolemic shock from extracellular fluid loss is difficult to quantify, it is known that hemorrhagic shock is most commonly due to trauma. In one study, 62.2% of massive transfusions at a level 1 trauma center were due to traumatic injury.

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