Module 8 Lesson 36: Administering Blood Products

The nurse has obtained a unit of packed RBCs from the blood bank for administration to a client. While preparing to administer the transfusion, the nurse is called to attend to an emergency involving another client. Before leaving to go to the other client, what should the nurse ask another staff member to do? 1. Return the blood to the blood bank 2. Place the blood in the nursing unit's refrigerator 3. Attach the blood to the client's IV line because the client's identity and the identifying information on the unit of blood have already been matched 4. Bring the unit of blood to the client's bedside and explain to the client that the blood will be infused once the emergency situation has been taken care of

1. Return the blood to the blood bank

How long should the nurse stay with the client at the beginning of the transfusion to monitor for a reaction?

15 mins

How many license nurses must check the blood and orders?

2 nurses

Two registered nurses confirming blood product compatibility and verifying client identity for a client who is to receive a unit of packed RBCs are comparing the name and number on the client's identification band with the name and number on the unit of blood. The nurses note that the numbers are not identical. What should the nurses do? 1. Hang the unit of blood 2. Contact the blood bank 3. Continue verifying client identity, then notify the health care provider 4. Ask the unit secretary to prepare another identification band for the client that contains the number noted on the unit of blood

2. Contact the blood bank

The nurse is monitoring a client receiving a blood transfusion. One hour after the transfusion is started, the client complains that her skin is extremely itchy. On assessing the client's skin, the nurse notes a rash and suspects a transfusion reaction. Which action should the nurse take after immediately stopping the transfusion? 1. Removing the IV catheter 2. Contacting the health care provider 3. Completing a transfusion reaction report 4. Rechecking the blood bag tags against the client's identification band

2. Contacting the health care provider

A client is brought to the emergency department by emergency medical services after sustaining a gunshot wound to the abdomen. The client, bleeding profusely, requires an immediate transfusion of whole blood, but his blood type is unknown. Which type of blood should the nurse ask the blood bank to deliver? 1. O-positive 2. O-negative 3. AB-positive 4. AB-negative

2. O-negative

The nurse hangs a unit of packed RBCs. Which action should be taken once the nurse has hung the blood and adjusted the flow rate? 1. Taking the client's vital signs 2. Staying with the client and monitoring him closely for 15 minutes 3. Asking the client whether he has ever had a reaction to a blood transfusion 4. Placing the call bell next to the client and instructing him to call if he experiences anything unusual

2. Staying with the client and monitoring him closely for 15 minutes

How soon must blood be administered after being received from the blood bank?

30 mins

What is the maximum length of time that should be used to administer 1 unit of blood?

4 hours (if administration of 1 unit exceeds 4 hours, blood product bag must be changed to fresh bag for extra time in order to prevent septicemia)

The nurse is caring for a client with breast cancer who has been undergoing chemotherapy. Blood tests indicate a low platelet count. A platelet transfusion is prescribed, and the nurse obtains the platelets from the blood bank. After carrying out the pretransfusion protocol, the nurse should administer the transfusion over what period of time? 1. 2 hours 2. 4 hours 3. 6 hours 4. 15 to 30 minutes

4. 15 to 30 minutes

Blood salvage

A type of autologous donation in which blood is suctioned from a client's body cavities, joint spaces, and other closed body sites during a procedure.

Universal recipient

AB positive

How often are vital signs and lung sounds checked?

Before transfusion, again after the first 15 mins of transfusion, and every hour until 1 hour has passed since transfusion was completed

What are the immediate signs of a transfusion reaction?

Chills and diaphoresis Muscle aches, back pain, chest pain Rashes, hives, itching, swelling Rapid, thready pulse Dyspnea, cough, wheezing Pallor and cyanosis Apprehension Tingling and numbness Headache N/V, abdominal cramping, diarrhea

Autologous donation

Donation of the client's own blood before a scheduled procedure or in anticipation of some other future need.

What are the delayed signs of a transfusion reaction?

Fever Mild jaundice Decreased hematocrit

Which culture cannot receive blood or blood products?

Jehovah's Witness

Universal donor

O negative

What should you do with the blood bag, attached labels, and transfusion record after a transfusion reaction?

Return them to the blood bank

Transfusion reaction interventions

Stop the transfusion, change the IV tubing down to the IV site, and keep the IV line open with 0.9% NS solution Notify HCP and blood bank Remain with client, observe signs and symptoms, take VS every 5 min Prepare to administer emergency medications as prescribed

What should the client be premedicated with if the client has a history of adverse reactions?

acetaminophen or diphenhydramine

What solution is blood administered with simultaneously?

normal saline

If this vital sign is elevated, notify the HCP before beginning the transfusion because it may be a reason to delay the transfusion and could mask symptoms of an acute transfusion reaction.

temperature

What are the checks required before administering blood products?

the health care provider's prescription, the client's identity, and the client's ID band and number, verifying that the name and number are identical to those on the blood component tag