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Monitoring and Post-transfusion Care

- Monitoring during blood transfusion is essential to detect any signs of transfusion reactions or complications. The nurse should:

- Verify the identity of the recipient and the blood product using two identifiers and check for compatibility before starting the transfusion.

- Use a filter needle or a blood administration set with a filter to prevent clots or debris from entering the IV line.

- Use normal saline as the only compatible solution to infuse with blood products.

- Start the transfusion slowly (2 mL/min) for the first 15 minutes and monitor vital signs closely. If no reaction occurs, increase the rate as ordered but do not exceed 4 hours for each unit of packed red blood cells (PRBCs).

- Monitor vital signs every 15 minutes for the first hour and then every hour until the end of the transfusion. Compare with baseline values and report any changes.

- Monitor for signs and symptoms of transfusion reactions or complications such as fever, chills, rash, itching, dyspnea, chest pain, back pain, hemoglobinuria, hypotension, tachycardia, shock, or DIC.

- Stay with the recipient for at least the first 15 minutes of the transfusion or until stable.

- Educate the recipient about potential adverse effects and instruct them to report any discomfort or unusual sensations immediately.

- Posttransfusion care involves evaluating the outcome of the transfusion and documenting relevant information. The nurse should:

- Assess vital signs at least once after completing the transfusion and compare with baseline values.

- Assess hemoglobin and hematocrit levels before and after the transfusion to evaluate its effectiveness.

- Assess fluid balance and electrolyte levels to monitor for fluid overload or hypocalcemia.

- Dispose of used blood bags and tubing according to infection control policies.

- Document the type and amount of blood product transfused, infusion time, vital signs

Questions on Monitoring and Post-transfusion Care

Correct Answer is B

Explanation

Incorrect: Administering a rapid bolus of normal saline is unnecessary and could lead to fluid overload in the client. The nurse should administer normal saline or another appropriate IV fluid at the prescribed rate if the client requires hydration before or after the transfusion, but not as a priming method.

Correct Answer is A

Explanation

No explanation

Correct Answer is C

Explanation

Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic reaction, it is not the immediate action. The nurse should first discontinue the transfusion and infuse normal saline as stated in option C.

Correct Answer is C

Explanation

Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction but do not provide the main benefit of minimizing the risk of future transfusion reactions as PRBCs do.

Correct Answer is B

Explanation

Incorrect: Stopping the blood transfusion is essential, but it is not the immediate action in this situation. The nurse's priority is to address the client's respiratory distress and ensure adequate oxygenation by administering oxygen, as stated in option B. Once the client is stable, the nurse should then notify the healthcare provider about the situation.Questions

Correct Answer is A

Explanation

No explanation

Correct Answer is ["A","B","D"]

Explanation

Assessing the client's blood pressure and heart rate is an important part of the overall assessment before the blood transfusion.

Correct Answer is A

Explanation

Placing the client in a supine position with legs elevated is not a priority action when a transfusion reaction is suspected. The priority is to stop the transfusion and assess the client's vital signs and symptoms.

Correct Answer is D

Explanation

Warming the platelets to room temperature before infusion is essential to prevent hypothermia in the client. Cold platelets can cause vasoconstriction and discomfort upon infusion.

Correct Answer is A

Explanation

Discontinuing the blood transfusion and removing the IV catheter is important, but the immediate action to address the client's respiratory distress is to raise the head of the bed and administer oxygen. Stopping the transfusion can follow after the client's respiratory status stabilizes.Questions

Correct Answer is B

Explanation

Incorrect: Albumin is a protein used to expand intravascular volume, especially in cases of hypoalbuminemia, but it does not have a significant role in clot formation or controlling bleeding.

Correct Answer is A

Explanation

Incorrect: Packed Red Blood Cells (PRBCs) are used to treat anemia and improve oxygenation but do not address clotting factor deficiencies.

Correct Answer is C

Explanation

Incorrect: Albumin is used for volume expansion in cases of hypoalbuminemia and fluid resuscitation in certain situations, but PRBCs are more effective for rapid volume replacement.

Correct Answer is D

Explanation

Correct: Albumin is the blood product of choice for addressing severe hypoalbuminemia. It is a protein that helps maintain oncotic pressure and regulates fluid balance within the blood vessels.

Correct Answer is A

Explanation

Incorrect: Packed Red Blood Cells (PRBCs) are used to improve oxygenation in anemic clients and are not the primary treatment for clotting factor deficiencies related to liver disease.Questions

Correct Answer is A

Explanation

Incorrect: Obtaining informed consent from the client is crucial but not the first action to be taken. The nurse should first verify the client's identity and blood type before seeking consent for the transfusion.

Correct Answer is D

Explanation

Correct: An elevated temperature of 38.5°C (101.3°F) may indicate a fever, which could be a sign of an infection or an adverse reaction to the transfusion. The nurse should report this vital sign alteration to the healthcare provider before proceeding with the transfusion to determine the appropriate course of action.

Correct Answer is C

Explanation

Incorrect: Filtering the blood product through a standard IV filter is not sufficient to remove any clots present in the blood product. Using a blood product that appears abnormal could lead to adverse reactions in the client, so it is essential to obtain a replacement from the blood bank.

Correct Answer is C

Explanation

Incorrect: Hypertension is not a contraindication for a blood transfusion. While the nurse should monitor blood pressure during the transfusion, hypertension alone does not preclude the need for a transfusion in a client with other indications for blood products.

Correct Answer is D

Explanation

No explanation

Incorrect: Plasma is not directly involved in the crossmatching process. The focus is on ensuring compatibility between red blood cells and the recipient's plasma.

Incorrect: The client with blood type B-positive (B+) can receive blood from donors with A-positive (A+), O-negative (O-), and O-positive (O+). However, B-positive (B+) blood is not compatible with the client's A-positive (A+) blood type.

Incorrect: Mixing the incompatible blood with normal saline will not resolve the incompatibility issue and is not a safe practice. The nurse should not proceed with the transfusion and should return the blood to the blood bank.

Correct: O-positive (O+) blood type can safely receive blood from the client with blood type O-negative (O-) because O-negative (O-) is the universal blood donor for Rh-negative individuals.

Incorrect: AB-positive (AB+) blood type cannot donate to AB-positive (AB+) individuals due to ABO incompatibility.Questions

Incorrect: Infusing normal saline to maintain hydration is important, but it is not the first action the nurse should take when a transfusion reaction is suspected. The nurse should first stop the transfusion and notify the healthcare provider.

Incorrect: Administering diuretics is not the priority intervention for TRALI. TRALI is caused by a reaction to plasma components, not fluid overload, and diuretics may not address the underlying cause.

Incorrect: Administering epinephrine is not the appropriate intervention for an acute hemolytic transfusion reaction. Epinephrine is used to treat anaphylactic reactions, not hemolytic reactions.

Incorrect: Obtaining a blood sample for repeat crossmatching is not indicated in an allergic transfusion reaction. Allergic reactions are related to hypersensitivity to plasma proteins and do not involve compatibility issues between red blood cells and plasma.Questions

Incorrect: Continuing the transfusion at a slower rate is not appropriate when the client is experiencing severe symptoms. The nurse should first stop the transfusion and then notify the healthcare provider.

Incorrect: An increase in hemoglobin level by 2 g/dL after the transfusion is a positive outcome, indicating a successful transfusion. There is no need to report this finding to the healthcare provider.

Incorrect: Generalized muscle weakness may occur for various reasons and may not be directly related to a delayed transfusion reaction. The nurse should prioritize reporting the slightly elevated temperature.

Incorrect: Placing the client in a supine position with legs elevated is not indicated for an allergic transfusion reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.

Incorrect: Notifying the healthcare provider for further evaluation is important, but it may not be the first intervention. The nurse should first take immediate actions to address the client's symptoms of orthostatic hypotension.Questions

Incorrect: Assessing the client's vital signs and baseline laboratory values is essential, but it is not the priority action for preventing a potential complication related to blood compatibility. The nurse should first confirm the client's blood type and Rh factor.

Incorrect: Lower back pain is not typically associated with allergic transfusion reactions. The nurse should provide information about symptoms that indicate an allergic reaction, such as itching, rash, and facial swelling.

Incorrect: Monitoring the client's vital signs during the transfusion is a standard practice, but it is not the primary intervention for preventing allergic transfusion reactions. Pre-medication with antihistamines is a more targeted approach.

Incorrect: Restarting the transfusion with a different blood product is not indicated in the presence of suspected TRALI. The nurse's priority is to manage the client's respiratory distress and discontinue the transfusion if necessary.

<p>Correct: Obtaining a sample for repeat crossmatching is essential to identify and select blood products that are less likely to cause an allergic reaction in the client. This step can help prevent future allergic transfusion reactions and ensure safer blood product selection.</p>
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