Difficulty: Medium
Average Score: 76%
Full-length
The nurse is preparing to hang a unit of blood on a client. The blood has been checked off with two RNs and the pre-infusion vitals recorded. The nurse is at the bedside monitoring the infusion. Shortly after beginning the infusion, the pump alarm sounds. The IV has infiltrated. No blood has yet reached the client. The client is a hard stick, and the nurse realizes that a line cannot be placed within the time frame to begin the infusion. Which action by the nurse is correct?
Correct answer
C
Rationale
Since no blood reached the client and IV access cannot be re-established within the time frame, the nurse should cancel the order and notify the provider to reassess the need for transfusion.