A nurse is caring for a patient who has received a blood transfusion.
What action should the nurse take to ensure transfusion safety during administration?
Verify the patient's identification only.
Maintain aseptic technique and infection control practices.
Administer blood products using old and sterile equipment.
Monitor the patient's condition only after the transfusion.
The Correct Answer is B
Choice A rationale:
Verifying the patient's identification is an essential step in patient safety, but it alone does not ensure transfusion safety.
Transfusion safety involves multiple steps beyond identification.
Choice B rationale:
Maintaining aseptic technique and infection control practices is crucial during a blood transfusion.
This includes using sterile equipment, wearing gloves, and following proper hand hygiene.
Infection can be a severe complication of transfusion if proper precautions are not taken.
Choice C rationale:
Administering blood products using old and sterile equipment is not a safe practice.
Blood transfusions require the use of fresh, sterile equipment to prevent contamination and ensure patient safety.
Choice D rationale:
Monitoring the patient's condition only after the transfusion is not sufficient to ensure safety.
Continuous monitoring during the transfusion is necessary to detect and respond to any adverse reactions promptly.
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Correct Answer is C
Explanation
"I'll verify the physician's order for the specific blood product."
Choice A rationale:
Selecting any available intravenous site for the transfusion without verifying the physician's order is unsafe and can lead to administering the wrong blood product or causing an adverse reaction in the patient.
Verifying the order is a critical step in ensuring patient safety during a blood transfusion.
Choice B rationale:
Using a blood administration set with additives may be necessary in some cases, but it is not the primary action the nurse should take before starting the transfusion.
Verifying the physician's order is the first and most crucial step.
Choice C rationale:
Verifying the physician's order for the specific blood product is essential to confirm that the correct blood type and unit are being administered to the patient.
This step ensures ABO and Rh compatibility and minimizes the risk of transfusion reactions.
Choice D rationale:
Administering the transfusion as quickly as possible is not appropriate and can be dangerous.
Transfusions should be administered at a controlled and appropriate rate to monitor for any adverse reactions.
Rushing the transfusion can increase the risk of complications.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should obtain post-transfusion laboratory tests immediately after the transfusion to assess the patient's response to the blood transfusion.
These tests may include a complete blood count (CBC) to evaluate hemoglobin and hematocrit levels.
Choice B rationale:
Returning any unused blood product to the blood bank is not the immediate action needed after a transfusion.
Post-transfusion laboratory tests and patient assessment take precedence.
Choice C rationale:
Removing the IV catheter without flushing it immediately after the transfusion is not appropriate.
The IV site should be maintained for a period after the transfusion to ensure there are no adverse reactions, and the catheter should be flushed according to the facility's protocol.
Choice D rationale:
Educating the patient about the procedure is important but should be done before the transfusion, not immediately after.
Immediate post-transfusion care involves monitoring the patient and obtaining necessary laboratory tests.
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