A nurse manager is providing an in-service for a group of nurses about thromboembolism.
Which of the following conditions should the nurse manager include as life-threatening? (Select All that Apply)

Choice A rationale

Notifying the provider is an important subsequent step, but it is not the immediate priority when a client experiences chills and back pain during a blood transfusion. These symptoms are indicative of a potential transfusion reaction, which requires immediate cessation of the transfusion to prevent further complications and potential harm to the client.

Choice B rationale

Covering the client with a blanket addresses the symptom of chills but does not stop the underlying cause or progression of a potential transfusion reaction. While comfort measures are important, the priority is to halt the administration of the causative agent to prevent further immunological or physiological responses that could escalate to a life-threatening event.

Choice C rationale

Stopping the transfusion is the immediate priority. Chills and back pain are classic signs of an acute hemolytic transfusion reaction, an immune-mediated response that can rapidly progress to severe complications, including renal failure, disseminated intravascular coagulation, and shock. Prompt cessation minimizes the volume of incompatible blood transfused and limits the severity of the reaction.

Choice D rationale

Assessing the client's skin for a rash is part of a comprehensive assessment for a transfusion reaction. However, stopping the transfusion takes precedence over this assessment. While a rash can indicate an allergic reaction, chills and back pain are more suggestive of a serious hemolytic reaction, demanding immediate interruption of the blood product.

Choice A rationale

Checking the expiration date with a second nurse is a critical safety measure, ensuring proper identification and viability of the blood product. This dual verification mitigates the risk of administering expired or incorrect blood, which could lead to severe immunological reactions such as acute hemolytic transfusion reactions due to complement activation and antigen-antibody complex formation. This adherence to protocol aligns with best practices for patient safety.

Choice B rationale

Priming blood tubing with dextrose 5% in water is contraindicated because dextrose solutions are hypotonic and can cause hemolysis of red blood cells. The osmotic gradient draws water into the erythrocytes, leading to cell lysis and the release of hemoglobin, which can result in renal damage and hyperkalemia. Normal saline (0.9% sodium chloride) is isotonic and is the only solution compatible for priming blood transfusion sets to maintain red blood cell integrity.

Choice C rationale

Inserting an IV with a 20-gauge or larger needle (e.g., 18-gauge) is recommended for blood transfusions. This larger bore minimizes shear stress on red blood cells during infusion, reducing the risk of hemolysis. Smaller gauges can cause mechanical trauma to the fragile erythrocytes as they pass through, potentially leading to the release of intracellular contents and adverse patient reactions.

Choice D rationale

Transfusing a blood product within 4 hours, not 5 hours, after removing it from refrigeration is the standard guideline. Exceeding this timeframe increases the risk of bacterial proliferation within the blood product, as temperatures rise above refrigeration levels. This can lead to severe febrile non-hemolytic transfusion reactions or even septic shock, compromising patient safety and treatment efficacy.

Choice E rationale

Checking vital signs before transfusion establishes a baseline for the client's physiological status. This baseline is essential for detecting early signs of transfusion reactions, such as fever, chills, or changes in blood pressure. Significant deviations from baseline vital signs during or after the transfusion indicate a potential adverse event, necessitating immediate intervention to ensure patient safety.