A nurse is preparing to administer a blood transfusion to a patient.
What should the nurse consider when selecting an intravenous site for the transfusion?

Choice A rationale:

Transfusion-related acute lung injury (TRALI) is characterized by acute respiratory distress and is usually not associated with abdominal symptoms.

TRALI is more common in patients receiving plasma-containing blood products.

Choice B rationale:

Transfusion-associated circulatory overload (TACO) occurs when a patient receives a volume of blood or blood products that exceeds their circulatory system's capacity.

Symptoms include dyspnea, orthopnea, tachypnea, and crackles on lung auscultation, which match the symptoms described in the question.

This condition is more likely when blood products are transfused too rapidly or in excessive volume.

Choice C rationale:

Allergic reactions to blood transfusions typically present with symptoms like itching, hives, and flushing, rather than the respiratory symptoms and crackles on lung auscultation described in the question.

Choice D rationale:

Febrile nonhemolytic reactions are characterized by fever and chills and do not typically manifest as dyspnea, orthopnea, tachypnea, or crackles on lung auscultation.

Choice A rationale:

Verify the patient's identification.

Rationale: Ensuring the correct patient is receiving the blood transfusion is a critical safety step.

Verifying the patient's identification helps prevent transfusion errors and ensures that the right blood product is administered to the right patient.

Choice B rationale:

Obtain informed consent.

Rationale: Obtaining informed consent is a necessary step before any medical procedure, including blood transfusions.

It ensures that the patient understands the risks, benefits, and alternatives to the transfusion and has the opportunity to ask questions and make an informed decision.

Choice E rationale:

Document the procedure accurately.

Rationale: Accurate documentation is essential for maintaining a complete record of the transfusion process.

It includes documenting the patient's identification, vital signs, the type and volume of blood product administered, any adverse reactions, and the patient's response to the transfusion.

This documentation serves as a legal and clinical record of the procedure.

Choice C rationale:

Monitor vital signs during the transfusion.

Rationale: While monitoring vital signs is important during a blood transfusion, it is not a responsibility before initiating the transfusion.

Vital sign monitoring occurs during the transfusion to detect any immediate adverse reactions or transfusion-related complications.

Choice D rationale:

Prepare the patient for an exchange transfusion.

Rationale: Preparing a patient for an exchange transfusion is not a nursing responsibility before initiating a routine blood transfusion.

Exchange transfusions are typically used for specific medical conditions, such as hemolytic disease of the newborn or sickle cell disease, and involve the removal and replacement of a large volume of blood.

Standard blood transfusions do not require this preparation.

For , fresh frozen plasma (FFP) is the most suitable blood product for increasing fibrinogen levels in a patient with hemophilia A.

For , the nursing responsibilities before initiating a blood transfusion include verifying the patient's identification, obtaining informed consent, and documenting the procedure accurately.

Monitoring vital signs is important but occurs during the transfusion, and preparing the patient for an exchange transfusion is not relevant to routine blood transfusions.