A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community.

Which of the following actions should the nurse plan to take

The correct answer is Choice C.

Choice A rationale: While additional staff may be needed, the primary focus during a mass casualty event is triage and immediate care. Choice B rationale: Media relations are important, but the nurse's priority is direct patient care. Choice C rationale: Assessing incoming clients and determining their medical needs is crucial for prioritizing care and allocating resources effectively. Choice D rationale: Discharging stable clients may be necessary in extreme circumstances, but it is not the immediate priority. The focus should be on providing care to the influx of injured patients.

Choice A reason

Setting the IV infusion pump to administer the blood over 6 hours is not the recommended rate for administering packed RBCs. Blood transfusions are typically given more rapidly, usually within 2 to 4 hours. The specific rate may vary depending on the client's condition and the provider's order.

Choice B reason

Administering the blood via a 21-gauge IV needle is not typically related to the administration of the packed RBCs. The appropriate gauge of the IV needle for blood transfusions depends on the client's condition and the type of transfusion. Larger-gauge needles are often used for blood transfusions to allow for a faster flow rate and prevent haemolysis of the blood cells.

Choice C reason

Checking the client's vital signs from the previous shift prior to the initiation of the transfusion is not sufficient for ensuring the client's safety during the blood transfusion. The nurse should assess the client's current vital signs, including temperature, heart rate, blood pressure, and respiratory rate, before initiating the transfusion. Monitoring vital signs is essential during the transfusion to detect any adverse reactions or changes in the client's condition.

Choice D reason

Rush the blood administration tubing with 0.9% sodium chloride prior to the transfusion is the correct answer. When preparing to administer a blood transfusion to an adult client with chronic anaemia, the nurse should rush the blood administration tubing with 0.9% sodium chloride (normal saline) prior to the transfusion. This process is called priming the tubing.

Priming the tubing helps remove any residual air from the tubing and ensures that the blood transfusion is administered smoothly without introducing air into the client's bloodstream. Air embolisms can be a serious complication, and priming the tubing with normal saline helps prevent this risk.