A registered nurse is managing the care of multiple clients on a medical-surgical unit and is preparing to initiate a transfusion of packed red blood cells (PRBCs) for a client with severe symptomatic anemia. Which actions by the nurse demonstrate correct safety principles to prevent administration errors and client injury? Select all that apply.
- Verify the client's two identifiers, blood type, and the unit identification numbers with a second registered nurse directly at the bedside.Cevap
- BDelegate baseline vital signs and monitoring during the first 15 minutes of the transfusion to the unlicensed assistive personnel.
- Prepare the blood administration set using dedicated Y-type tubing with an in-line filter and prime it exclusively with 0.9% sodium chloride.Cevap
- DPrioritize initiating the blood transfusion over assessing another assigned client who is reporting sudden, severe chest pain.
- Remain continuously present at the client's bedside for the first 15 minutes of the transfusion to monitor for early signs of an adverse reaction.Cevap
- FPiggyback the blood product into a continuously infusing intravenous line of lactated Ringer's solution to maintain adequate hydration.
Cevap
The correct safety interventions to prevent injury during blood administration are verifying identifiers with a second registered nurse at the bedside, using dedicated Y-type tubing primed only with 0.9% sodium chloride, and remaining at the bedside for the first 15 minutes.
Administering blood products requires meticulous safety protocols to prevent catastrophic errors. Verifying the client's identity and blood product details with a second RN at the bedside ensures the correct blood is given to the correct client. Using dedicated Y-tubing primed exclusively with 0.9% sodium chloride prevents hemolysis and clotting within the line. Remaining at the bedside for the first 15 minutes is crucial because severe, life-threatening transfusion reactions typically occur within this initial timeframe, requiring immediate nursing intervention.
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Safe administration of blood products requires strict adherence to verification protocols, use of compatible IV fluids (only 0.9% sodium chloride), direct RN monitoring during the critical first 15 minutes, and appropriate clinical prioritization.