Fundamentals of Nursing Q 399
A client is receiving a first-time blood transfusion of packed RBC. How long should the nurse stay and monitor the client to ensure a transfusion reaction will not happen?
A. 15 minutes
B. 30 minutes
C. 45 minutes
D. 60 minutes
Correct Answer: A. 15 minutes
Usually, a transfusion reaction occurs within 15 minutes of a transfusion. For each unit of blood transfused, monitor the patient before starting the transfusion (baseline observation; 15 minutes after starting the transfusion; at least every hour during transfusion; and carry out a final set of observations 15 minutes after each unit has been transfused.
Option B: Staying with the patient for 30 minutes might be too long. Acute reactions may occur in 1% to 2% of transfused patients. Rapid recognition and management of the reaction may save the patient’s life. Once immediate action has been taken, careful and repeated clinical assessment is essential to identify and treat the patient’s problems.
Option C: 45 minutes of staying and monitoring the patient for transfusion reactions is too long. All suspected acute transfusion reactions should be reported immediately to the blood transfusion center and to the doctor responsible for the patient. With the exception of urticarial allergic reactions and febrile non-hemolytic reactions, all are potentially fatal and require urgent treatment.
Option D: Most transfusion reactions occur during the first 15 minutes of transfusion. 60 minutes is too long. However, transfusion-transmitted infections are the serious delayed complications of transfusion. Since a delayed transfusion reaction may occur days, weeks, or months after the transfusion, the association with the transfusion may not be recognized.