A licensed practical nurse (LPN) is assisting with the care of a client who is post-operative following an open cholecystectomy and is currently receiving a packed red blood cell (PRBC) transfusion. Which of the following actions by the LPN demonstrate appropriate risk reduction strategies? Select all that apply.
- Stopping the transfusion immediately if the client develops a sudden onset of lower back pain and dyspnea.Cevap
- Verifying the client's identity, blood type, and the packed red blood cell unit with the registered nurse (RN) at the bedside before administration.Cevap
- Obtaining and documenting the client's baseline vital signs immediately prior to the initiation of the transfusion.Cevap
- DWaiting until the end of the shift to report a post-operative hemoglobin level of because the client is currently receiving blood.
- EDocumenting a mid-transfusion heart rate of and a blood pressure of as expected findings without notifying the RN.
- FAccepting a delegation from the RN to independently spike the blood bag and initiate the transfusion using the existing intravenous line.
Cevap
The appropriate risk reduction strategies are stopping the transfusion for signs of a hemolytic reaction (back pain and dyspnea), verifying the client and blood product with an RN at the bedside, and obtaining baseline vital signs immediately prior to the transfusion.
Stopping the transfusion for signs of a hemolytic reaction, verifying the blood product with an RN, and obtaining baseline vital signs are essential risk reduction strategies. These actions ensure the right patient receives the right blood product, establish a baseline to identify adverse reactions, and prevent severe harm if an acute reaction occurs.
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Reduction of Risk Potential During Blood Administration