Practice Quiz

CCRN Critical Care Nursing

Category - Adult

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A patient with Hemoglobin of 8.2 is receiving an infusion of packed cells. What is the most effective thing the nurse can do to assess for an adverse reaction to the blood?
  1. Educate the patient on the signs and symptoms of transfusion reaction and ask the patient to verbalize the signs and symptoms back to you.
  2. Stay in the room with the patient for the first fifteen minutes of the blood transfusion.
  3. Ensure the call light is in the room next to the patient and chart by the telemetry monitors.
  4. Start the infusion out slowly and communicate to the nurse’s aid that vitals must be done every fifteen minutes.
Explanation
Answer: B- The best way to assess for a reaction is to stay by the bedside. Most reactions occur within the first fifteen minutes of transfusion. The telemetry monitor will note changes in heart rate but not difficulty breathing.
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