Fundamentals of Nursing Q 446
After terminating the transfusion during a reaction, which action should the nurse immediately be taken next?
A. Run a solution of 5% dextrose in water.
B. Run normal saline at a keep-vein-open rate.
C. Remove the IV line.
D. Fast drip 200ml normal saline.
Correct Answer: B. Run normal saline at a keep-vein-open rate.
The nurse will infuse normal saline at a KVO rate to keep the patency of the IV line while waiting for further orders from the physician. A transfusion reaction evaluation request form typically is used to document signs and symptoms of a suspected reaction so that the blood bank can use this information, in conjunction with laboratory testing, to arrive at a likely diagnosis. The blood bag, along with the infusion set and anything else attached to the set, should be sent with the transfusion reaction evaluation request.
Option A: IV solution containing dextrose will hemolyze the red cells. IV solution containing dextrose in water will hemolyze red cells.Only isotonic, calcium-free IV solutions should be added to, or come in contact with blood products. Calcium may bind with the citrate anticoagulant and promote clotting in the tubing. Excess glucose and/or dextrose causes hemolysis and shortens red cell survival.
Option C: The nurse will not remove the IV line because then there would be no IV access route. Transfusion reaction treatment varies with the reaction. Diphenhydramine and acetaminophen are some of the most commonly used drugs for treating mild allergic and febrile nonhemolytic reactions. For other reactions, expert consultation should be considered. In cases of acute hemolytic reaction, baseline laboratory tests should be performed and urine should be kept flowing, possibly with alkalinization.
Option D: Doing a fast drip will potentially lead to congestion and is not done without the physician’s order. Volume overload may require diuretics. TRALI is treated with oxygen and supportive care, which may involve intubation. Bacterial contamination may involve blood pressure support and antibiotics. Because anaphylaxis is treated emergently according to hospital protocol, usually with epinephrine and diphenhydramine, there may not be time for consultation until after the patient is stabilized.