Difficulty: Medium
Average Score: 94%
Full-length
A client diagnosed with severe anemia is to receive 2 U of packed red blood cells. Prior to starting the blood transfusion, the nurse must:
Correct answer
A
Rationale
A baseline set of vital signs is necessary to determine if any transfusion reactions occur as the blood product is being administered. The only companion fluid to be used during a blood transfusion is normal saline. The calcium in Ringer's lactate can cause clotting. Only a blood administration set should be used. A microdrip tube would cause lysis of the red blood cells. Proper identification of the recipient and the blood product must be validated by at least two people.