Question

A primary health care provider prescribes a unit of packed red blood cells for a client with a low hemoglobin level. which action should be implemented by the nurse when administering this transfusion? (select all that apply)

a. adjust the flow rate to 20 drops per minute for the first 15 minutes
b. after 15 minutes, vital signs should be taken for every 15-30 minutes
c. ensure that an 18-gauge needle is used for administering the blood transfusion
d. discontinue the blood transfusion if it extends beyond 4 hours after its initiation
e. stay with the client for 15 minutes after initiating the blood transfusion while taking vital signs every 5 minutes

Answer 1

The nurse should adjust the flow rate, take vital signs, and stay with the client when administering a packed red blood cell transfusion.

Step-by-step explanation:

When administering a transfusion of packed red blood cells, the nurse should:

1. Adjust the flow rate: The flow rate should be adjusted to 20 drops per minute for the first 15 minutes. This slow rate allows the nurse to monitor the client for any adverse reactions.
2. Take vital signs: After the initial 15 minutes, vital signs should be taken every 15-30 minutes. This helps monitor the client's response to the transfusion.
3. Stay with the client: The nurse should stay with the client for 15 minutes after initiating the transfusion and take vital signs every 5 minutes. This allows for immediate recognition of any potential adverse effects.