Difficulty: Medium
Average Score: 62%
Simulated
Passage / Scenario
1230:0.9% sodium chloride 500 mL bolus then 100 mL/hr.
Type and cross match for 2 units of packed RBCs.
Repeat WBC, hemoglobin, and hematocrit STAT.
Delay endoscopy.
2 L/min O2 via nasal cannula.
1330:
2 units packed RBCs IV over 4 hr.
Repeat WBC, hemoglobin, and hematocrit at transfusion
completion STAT.
The nurse is reviewing the client's medical record.
The nurse is assisting with the care the client prior to a blood transfusion
The nurse is assisting with the care the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.
Correct answer
B,C,D
Rationale
Ensure two nurses confirm the information on the blood label: Before initiating a blood transfusion, two nurses must verify the client's identity, blood type, and compatibility with the donor blood. Obtain a large-bore IV catheter: A large-bore IV catheter (18 20 gauge) is necessary to facilitate the transfusion of packed red blood cells. Witness the client signing a consent for transfusion: A blood transfusion is an invasive procedure requiring informed consent.