Blood Transfusion

A nurse is assessing a client who is receiving one unit of packed red blood cells (RBCs) to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mmHg. Which action should the nurse take first?

• Obtain a blood specimen.

• Slow infusion of blood.

• Inform the healthcare provider.

• Stop the infusion of blood.

Answer explanation

The client is experiencing an acute hemolytic transfusion reaction.

The greatest risk to this client is injury from receiving additional blood, therefore, the first action the nurse should take is to stop the infusion of blood.

What can cause this reaction?

A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately?

• Blood pressure 110/60

• Temperature 101.3 F

• Poor skin turgor and pallor

• Heart rate of 100 bpm.

Answer explanation

A fever should be reported immediately and the transfusion should be stopped. All other assessment findings are expected.

Why are poor skin turgor (and pallor) and heart rate of 100 beats per minute expected?

A new graduate nurse has a client who will be receiving packed red blood cells (PRBCs). When discussing the blood product administration with her preceptor, the student nurse makes the following statements. Which statement below indicates a need for further teaching about blood product administration?

• The blood transfusion needs to be completed within four hours.

• The nurse will use the same IV drip rate throughout the infusion.

• The packed red blood cells (PRBCs) are connected by Y tubing to normal saline.

• No medications should be infused through the same IV while the blood is infusing.

Answer explanation

When do we adjust the IV infusion rate when administering PRBCs?

What is the maximum amount of time a blood product can hang/infuse?

What medications are compatible with blood?

A nurse is monitoring a client that is receiving a unit of packed red blood cells (PRBCs). Ten minutes after starting the transfusion, the client starts to experience uticaria, bronchospasm, hypotension, and tachycardia. Which transfusion reaction is the client experiencing?

• Bacterial contamination

• Severe allergic reaction

• Mild to moderate allergic reaction

• Transfusion-related acute lung injury (TRALI)

Answer explanation

What does the nurse do if a patient is experiencing a mild to moderate allergic reaction?

What interventions for a severe (anaphylactic) reaction?

Which client is at the highest risk for transfusion-associated circulatory overload (TACO) while receiving blood products?

• A 49 year old with no past medical history was in a motor vehicle accident.

• A 78 year old with kidney failure.

• A 12 year old with severe anemia.

• A 36 year old with blood loss from surgery.

Answer explanation

Why are older adults (>70 years old) and infants at the highest risk?

What are some interventions that can help decrease the risk of a TACO reaction for our high risk clients?

A client is receiving intravenous fluid through an IV. Upon assessment the nurse notes redness, tenderness, pain, warmth along the course of vein starting at the access site with a red streak along the vein. Which of the following actions will the nurse take next?

• Check IV patency with 0.9% NaCl 10mL syringe.

• Administer antihistamine for an allergic reaction.

• Stop the infusion and discontinue the IV line.

• Start a new IV line in the other extremity.

Answer explanation

What is phlebitis?

What are some risk factors or causes of phlebitis?

A client is receiving a unit of packed red blood cells (PRBCs). Pre-transfusion vital signs are BP 110/70, HR 84, RR 16, T 37 C, O2 sat 98% on room air.

After 15 minutes, the client begins to complain of chills, headache, and low back pain. Vital signs at this time are BP 88/68, HR 104, RR 24, T 38 C, O2 sat 97% in RA. The nurse suspects the client may be having which type of transfusion reaction?

• Febrile, non-hemolytic

• Bacterial contamination

• Severe allergic reaction (anaphylaxis)

• Acute hemolytic transfusion reaction (AHTR)

Answer explanation

What clues helped you identify this reaction?

What is our next nursing action?

An adult client is in need of a unit of packed red blood cell transfusion and the nurse is preparing items needed for a rapid transfusion. Select all that apply for the procedure:

• 
• 
• 
• 

Answer explanation

Why do we need to prime the Y tubing with 0.9% NaCl before adding the blood?

A nurse is caring for a client receiving a unit of packed red blood cells (PRBCs) with clinical manifestations of urticaria, nausea, abdominal pain, bronchospasm, and hypotension. After the nurse stops the transfusion what are the nurse's priority actions?

• Notify the healthcare provider and administer antipyretics as ordered.

• Change administration set and infuse normal saline, notify healthcare provider.

• Discontinue IV site and start a new IV on the other extremity.

• Notify blood bank and administer antihistamines, corticosteroids, and epinephrine as ordered.

Answer explanation

What distinguishes a mild/moderate allergic reaction from an anaphylactic (severe) allergic reaction?

A nurse is caring for a client who has just had a central line catheter (central venous access device) placed in their right subclavian vein. Which of the following nursing actions are appropriate with this device?

• Maintain port patency by flushing the ports with 5 ml normal saline every 12-24 hours.

• Perform dressing changes using medical asepsis.

• Ensure a chest x-ray is completed to verify correct placement of the device.

• Manipulate the length of the external part of the catheter as needed.

Answer explanation

1. Hand hygiene is the most critical step in preventing infections associated with central lines.

When else might a dressing need changed if it hasn't been 7 days yet?

Flushing: why, how often, how much?

Complications: what s/s are we assessing?

Education: what does the client need to understand.