The nurse infuses a unit of blood, but after 4 hours the blood infusion is not complete. Which action should the nurse implement?
a. Check the intravenous (IV) access for pa-tency.
b. Increase the infusion rate of the blood.
c. Discontinue the blood infusion.
d. Assess the patient for an ABO mismatch.
C
The nurse infuses whole blood within a 4-hour time limit; thus, if the infusion is incomplete at the end of 4 hours, the nurse must discontinue it to decrease the risk of adverse transfusion effects because the blood has warmed sufficiently to promote microorganism growth. Checking the IV access for patency is a reasonable intervention because at the end of 4 hours the IV access is likely to have fibrin deposits or small accumulations that impede infusion rates. Nevertheless the nurse must discontinue the blood infusion because after 4 hours, the blood is not safe to infuse. He or she avoids increasing the infusion rate to complete the transfusion because it increases the risk of fluid volume overload. Although delayed transfusion reactions occur, if a mismatch exists between the blood and the patient, the patient is more likely to manifest reaction within the first few minutes of the transfusion because this is when most transfusion reactions occur.
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