THE HUMAN IMMUNE SYSTEM
TRANSFUSION
|
Question
[CLICK ON ANY CHOICE TO KNOW THE RIGHT ANSWER]
|
|
|
Warming the blood prior transfusion
|
|
|
Informing the client that the transfusion usually takes 4 to 6 hours.
|
|
|
Documenting blood administration in the client chart.
|
|
|
Instructing the client to report any itching, chest pain, or dyspnea.
|
Detailed explanation-1: -Which nursing intervention takes highest priority when caring for a newly admitted client who’s receiving a blood transfusion? Instructing the client to report any itching, chest pain, or dyspnea. Rationale: This will help the nurse take immediate action incase a reaction happens during a transfusion.
Detailed explanation-2: -Assessment is the first step of the nursing process and takes priority over all other steps. It is essential that you complete the assessment phase of the nursing process before you implement nursing activities.
Detailed explanation-3: -The Correct Answer is : C. Vital signs. The nurse must assess the vital signs before and 15 minutes after the procedure so that any changes during the transfusion may indicate a transfusion reaction is happening.
Detailed explanation-4: -If blood transfusion reaction occurs: STOP THE TRANSFUSION. Place the client in Fowler’s position if with Shortness of Breath and administer O2 therapy. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. Notify the physician immediately.
Detailed explanation-5: -As soon as you suspect a transfusion reaction: Stop the transfusion immediately and activate emergency procedures if required. Check and monitor the patient’s vital signs. Maintain intravenous (IV) access (do not flush the existing line and use a new IV line if required).