Which does the nurse implement to initiate a blood transfusion?
1. Begin infusion at 2 ml/min.
2. Establish a single-line infusion
3. Check vital signs in 30 minutes.
4. Shake blood to mix preservative.
1
1. To begin the blood administration, the nurse infuses the blood very slowly at 2 ml/min to prevent the infusion of a large-volume bolus of potentially incompatible blood. Most transfusion reactions occur in the first 15 minutes of the infusion, so the nurse continues the slow rate for 15 minutes while closely monitoring the client for a transfusion reaction.
2. The nurse can infuse blood products through Y-tubing.
3. The nurse evaluates the client's vital signs within 5 minutes of starting the infusion for 15 minutes and then every 15 minutes or according to agency policy.
4. The nurse avoids shaking blood products because violent movement damages erythrocytes and increases hemolysis.
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