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Zorluk: KolayPharmacological and Parenteral Therapies

A nurse is assigned to care for a client who requires a transfusion of packed red blood cells (PRBCs) due to symptomatic anemia. Which of the following actions must the nurse perform to ensure safe administration of the blood product? Select all that apply.

  1. Obtain and document the client's baseline vital signs immediately prior to initiating the transfusion.Cevap
  2. Verify the client's identity and the blood product information with a second registered nurse at the bedside.Cevap
  3. Check the client's medical record to confirm that a signed informed consent document is present.Cevap
  4. D
    Prime the Y-type blood administration tubing with a continuous infusion of 5% dextrose in water (D5W).
  5. E
    Delegate the initial 15-minute vital sign assessment to the unlicensed assistive personnel (UAP).
  6. F
    Program the infusion pump rate so that the unit of packed red blood cells infuses over a 6-hour period.

Cevap

The nurse must obtain baseline vital signs, verify the client and blood product with a second registered nurse, and confirm that informed consent is signed in the medical record.
Safe blood transfusion administration requires strict adherence to core safety protocols. Verifying the client and product with a second nurse prevents catastrophic incompatibility. Taking baseline vital signs establishes a reference point to detect adverse reactions early. Finally, ensuring informed consent is signed protects the client's legal rights and confirms they understand the procedure's risks.

Adım Adım Çözüm

1
Review the prescribed orders and the client's medical record.
The nurse confirms the prescription for PRBCs and verifies that a signed informed consent is present.
Blood transfusions carry significant risks, and legal consent must be documented prior to starting the procedure.
2
Prepare the necessary equipment and perform pre-transfusion assessments.
The nurse primes the blood tubing exclusively with 0.9% sodium chloride and obtains baseline vital signs.
Normal saline is the only compatible fluid for blood transfusions. Baseline vital signs are required to quickly identify any deviations indicating a transfusion reaction.
3
Verify the blood product at the client's bedside.
The nurse and a second registered nurse confirm the client's identity, blood type, and the donor unit numbers.
A two-nurse independent verification is a mandatory safety standard to prevent fatal ABO incompatibility reactions.

Anahtar Kavram

Safe administration protocols for blood products
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Konular

Pharmacological and Parenteral Therapies

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