A patient receiving a unit of packed red blood cells for hypovolemic shock is demonstrating signs of a transfusion reaction. In which order should the nurse provide care to this patient?
1: Stop the transfusion and notify the physician
2: Compare the blood slip with the unit of blood
3: Assess vital signs and associated manifestations
4: Save the blood bag and tubing for laboratory analysis
5: Collect urine and venous blood samples according to policy
Correct Answer: 1, 3, 2, 4, 5
If manifestations of a blood transfusion reaction occur, the first step is to immediately stop the infusion and notify the physician. The second step is to assess vital signs and assess for other manifestations. The third step is to compare the blood slip with the unit of blood to ensure that an identification error was not made. The fourth step is to save the blood bag and any remaining blood for return to the laboratory for testing to determine the cause of the reaction. The fifth step is to follow organizational policy for collecting urine and venous blood samples.
You might also like to view...
The nurse is contributing to the plan of care for a patient who has a bone fracture that is splintered or shattered into numerous fragments. Which of the following describes this type of fracture?
a. Avulsion b. Greenstick c. Comminuted d. Impacted
Poor nutrition and subsequent skin breakdown is associated with which of the following lab results?
a. Serum albumin of 3.0 b. Serum transferrin of 250 c. Cholesterol of 200 d. none of the above
You need to give a person oral hygiene. Because the person is unconscious, she is at risk for:
a. Periodontal disease b. Plaque c. Tartar d. Aspiration
Electrolytes are essential for many body functions, and require a
1. wide level range. 2. low level range. 3. narrow level range. 4. high level range.