A nurse is caring for a client who has a traumatic brain injury.
Which of the following should the nurse understand as a consequence of a traumatic brain injury?

Choice A rationale

Checking the expiration date with a second nurse is a critical safety measure, ensuring proper identification and viability of the blood product. This dual verification mitigates the risk of administering expired or incorrect blood, which could lead to severe immunological reactions such as acute hemolytic transfusion reactions due to complement activation and antigen-antibody complex formation. This adherence to protocol aligns with best practices for patient safety.

Choice B rationale

Priming blood tubing with dextrose 5% in water is contraindicated because dextrose solutions are hypotonic and can cause hemolysis of red blood cells. The osmotic gradient draws water into the erythrocytes, leading to cell lysis and the release of hemoglobin, which can result in renal damage and hyperkalemia. Normal saline (0.9% sodium chloride) is isotonic and is the only solution compatible for priming blood transfusion sets to maintain red blood cell integrity.

Choice C rationale

Inserting an IV with a 20-gauge or larger needle (e.g., 18-gauge) is recommended for blood transfusions. This larger bore minimizes shear stress on red blood cells during infusion, reducing the risk of hemolysis. Smaller gauges can cause mechanical trauma to the fragile erythrocytes as they pass through, potentially leading to the release of intracellular contents and adverse patient reactions.

Choice D rationale

Transfusing a blood product within 4 hours, not 5 hours, after removing it from refrigeration is the standard guideline. Exceeding this timeframe increases the risk of bacterial proliferation within the blood product, as temperatures rise above refrigeration levels. This can lead to severe febrile non-hemolytic transfusion reactions or even septic shock, compromising patient safety and treatment efficacy.

Choice E rationale

Checking vital signs before transfusion establishes a baseline for the client's physiological status. This baseline is essential for detecting early signs of transfusion reactions, such as fever, chills, or changes in blood pressure. Significant deviations from baseline vital signs during or after the transfusion indicate a potential adverse event, necessitating immediate intervention to ensure patient safety.

Choice A rationale

Slurred speech, also known as dysarthria, is typically associated with neurological conditions affecting motor control of speech, such as stroke or Parkinson's disease. While severe anemia might cause generalized weakness, it is not a direct or common symptom of iron deficiency impacting speech articulation.

Choice B rationale

Confusion can be a symptom of severe or prolonged anemia due to inadequate oxygen delivery to the brain. However, it is more commonly associated with acute and severe reductions in hemoglobin or other systemic conditions that impair cerebral perfusion, rather than a primary symptom of typical iron deficiency anemia.

Choice C rationale

Pain is not a direct or primary symptom of iron deficiency anemia. Pain is more characteristic of other types of anemia, such as sickle cell anemia (due to vaso-occlusive crises) or pernicious anemia (due to neurological involvement), or due to conditions causing the iron deficiency.

Choice D rationale

Fatigue is the most common and often the earliest symptom of iron deficiency anemia. This occurs because iron is crucial for hemoglobin synthesis, and insufficient hemoglobin impairs oxygen transport to tissues, leading to cellular hypoxia and a profound lack of energy. Normal hemoglobin levels for adults are typically 12-16 g/dL for females and 13-17 g/dL for males.