A client has a gastrointestinal hemorrhage and is prescribed two units of packed red blood cells. What actions should the nurse perform prior to hanging the blood? (Select all that apply.)
a. Ask a second nurse to double-check the blood.
b. Prime the IV tubing with normal saline.
c. Prime the IV tubing with dextrose in water.
d. Take and record a set of vital signs.
e. Teach the client about reaction manifestations.
ANS: A, B, D, E
Prior to starting a blood transfusion, the nurse asks another nurse to double-check the blood (and client identity), primes the IV tubing with normal saline, takes and records a baseline set of vital signs, and teaches the client about manifestations to report. The IV tubing is not primed with dextrose in water.
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