An older client is prescribed a blood transfusion of two units packed red blood cells. What should the nurse do when providing the blood to this client? Select all that apply.

Question

1. Place the client on a heart monitor.
2. Administer each unit over two to four hours.
3. Provide a diuretic between the two units as prescribed.
4. Carefully assess the intravenous access site for infiltration.
5. Monitor vital signs and urine output during the transfusion.

Answer 1

2. Administer each unit over two to four hours.
3. Provide a diuretic between the two units as prescribed.
4. Carefully assess the intravenous access site for infiltration.
5. Monitor vital signs and urine output during the transfusion.

Explanation: 1. The client does not need heart or telemetry monitoring just because they are getting a transfusion. The nurse does closely assess for tachycardia or other signs of fluid overload or pulmonary edema.
2. Transfusions for older people should be given slowly over a two- to four-hour period.
3. If several units of packed cells are to be infused, often a diuretic is provided between units to prevent fluid overload and congestive heart failure.
4. Older people have more fragile veins. The intravenous site should be frequently assessed for signs of infiltration.
5. Because of the risk of heart failure from fluid overload, the nurse should monitor the older client's lung sounds, vital signs, and urinary output during the transfusion process. A diuretic such as furosemide is often required between administration of units.