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Difficulty: MediumAccident, Error, and Injury Prevention

A nurse is caring for a client who just underwent a percutaneous liver biopsy and is now prescribed a packed red blood cell (PRBC) transfusion for acute blood loss. Which interventions are essential for the nurse to implement to prevent accidents, errors, and injury? Select all that apply.

  1. Verify the client's identity, blood type, and the PRBC unit with a second registered nurse at the bedside.Answer
  2. Ensure the blood product is administered through a dedicated IV line primed only with 0.9% sodium chloride.Answer
  3. Position the client on their right side with a rolled towel placed under the biopsy site.Answer
  4. D
    Delegate the continuous monitoring of the client during the first 15 minutes of the transfusion to an unlicensed assistive personnel (UAP).
  5. E
    Piggyback a scheduled IV antibiotic into the PRBC infusion line to guarantee timely medication delivery.
  6. F
    Place the client in a high-Fowler's position immediately following the procedure to promote optimal chest expansion.

Answer

The correct actions are to verify the client and blood product with a second registered nurse, ensure the use of a dedicated IV line with 0.9% sodium chloride, and position the client on their right side with a towel under the biopsy site.
Preventing injury after a liver biopsy requires positioning the client on their right side to apply direct pressure to the liver capsule, minimizing the risk of hemorrhage. Safe administration of blood products requires dual verification by two registered nurses at the bedside to prevent fatal ABO incompatibility errors. Additionally, blood products must only be infused with 0.9% sodium chloride to prevent hemolysis of the red blood cells in the IV tubing.

Step-by-Step Solution

1
Evaluate the safety and infection control requirements for blood administration.
Identify the need for dual registered nurse verification and a dedicated line primed only with normal saline.
Strict protocol adherence prevents life-threatening ABO incompatibility and hemolysis of the transfused cells.
2
Determine the optimal post-procedural safety positioning for a liver biopsy.
Select right-side positioning with direct pressure applied to the area.
The liver is a highly vascular organ; applying direct pressure to the biopsy site is critical to prevent internal hemorrhage.
3
Assess the appropriateness of task delegation during the high-risk initiation of a transfusion.
Recognize that the registered nurse must personally conduct the continuous 15-minute monitoring.
Monitoring for subtle, early signs of an adverse transfusion reaction requires independent clinical judgment that cannot be delegated to a UAP.

Key Concept

Integration of safe blood administration protocols, appropriate delegation, and post-procedural injury prevention.
Estimated Time:1m 30s
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Topics

Accident, Error, and Injury Prevention

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