The nurse is administering blood. What should the nurse do to detect a blood reaction as quickly as possible?
a. Remain with the patient during the first 15 minutes.
b. Transfuse the blood at 10 mL/min.
c. Monitor vital signs q 1 hour.
d. Transfuse blood at 50 gtt/min.
A
Remain with the patient during the first 15 minutes of a transfusion. Most transfusion reactions occur within the first 15 minutes of a transfusion. The initial flow rate during this time should be 2 mL/min, or 20 gtt/min. Initially infusing a small amount of blood component minimizes the volume of blood to which the patient is exposed, thereby minimizing the severity of a reaction. Monitor the patient's vital signs at 5 minutes, at 15 minutes, and every 30 minutes until 1 hour after transfusion or per agency policy. Frequent monitoring of vital signs will help to quickly alert the nurse to a transfusion reaction.
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