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Chapter 23: Problem 64

The oncology client has ordered two units of blood to be infused. What is the nurse’s highest priority? ? A. Obtain vital signs prior to transfusion ? B. Use an infusion pump for accuracy ? C. Infuse the blood slowly for the first 10–15 minutes ? D. Determine proper type and cross-match it

Short Answer

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A. Obtain vital signs prior to transfusion B. Use an infusion pump for accuracy C. Infuse the blood slowly for the first 10–15 minutes D. Determine proper type and cross-match it Answer: D. Determine proper type and cross-match it

Step by step solution

01

Analyze Choice A

Choice A: Obtain vital signs prior to transfusion. Obtaining vital signs is an essential step in ensuring patient safety and monitoring the patient's condition before, during, and after a transfusion. Vital signs, such as blood pressure, pulse, and temperature, can help detect adverse reactions or complications during the transfusion process.
02

Analyze Choice B

Choice B: Use an infusion pump for accuracy. An infusion pump can help maintain a consistent and accurate flow rate of the blood, but it is not the highest priority. While using an infusion pump can be beneficial, it does not take precedence over other safety measures, such as obtaining vital signs or ensuring the proper blood type and compatibility.
03

Analyze Choice C

Choice C: Infuse the blood slowly for the first 10–15 minutes. Infusing blood slowly during the initial phase of the transfusion (10-15 minutes) allows time for monitoring the patient for potential adverse reactions. While this step is essential, it can be argued that other safety measures, such as obtaining vital signs and ensuring proper blood compatibility, should be considered before the actual infusion process.
04

Analyze Choice D

Choice D: Determine proper type and cross-match it. One of the highest priorities during a blood transfusion is to ensure the proper blood type and compatibility. Transfusion reactions can occur when incompatible blood is given to a patient, leading to life-threatening complications and adverse reactions. Therefore, correctly identifying and cross-matching blood types are essential to guaranteeing patient safety and minimizing risks associated with transfusion.
05

Determine the Highest Priority

Based on analyzing all the choices, it's evident that Choice D: Determine proper type and cross-match it, holds the highest priority in ensuring patient safety during a blood transfusion. While the other steps are essential, ensuring the correct blood type and compatibility is paramount to avoid life-threatening complications during the transfusion process.

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Most popular questions from this chapter

A client with Hodgkin’s disease is scheduled for a cyclophosphamide (Cytoxan) infusion. Which of the following manifestations causes the nurse the most concern? ? A. Blood in the urine ? B. Reports of a feeling of nausea ? C. White patches on the tongue ? D. Client weight gain

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