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Which nursing action is important when transfusing packed red blood cells to a client with a diagnosis of anemia?

A. Assessing the client for fluid overload
B. Monitoring the client's response, particularly within the first 10 minutes
C. Assuring that the transfusion flows at a consistent rate during the procedure
D. Having the client tested for human immunodeficiency virus (HIV) before administering the blood transfusion

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Final answer:

The correct answer is option B. Monitoring the client's response, particularly within the first 10 minutes

Step-by-step explanation:

When transfusing packed red blood cells to a client with anemia, specific nursing actions are critical. The most important action is monitoring the client's response, particularly within the first 10 to 15 minutes of the transfusion, as this is when acute transfusion reactions are most likely to occur. This monitoring includes watching for signs of allergic reactions, fever, chills, or any other adverse effects that could indicate a possible hemolytic transfusion reaction or other complications.

While ensuring the transfusion flows at a consistent rate and assessing for fluid overload are also important considerations, the initial observation period is imperative for patient safety. Testing for HIV before administering a blood transfusion is not an immediate action associated with the transfusion process itself, as donated blood is already screened for infectious diseases, including HIV, before being used for transfusion.

Pretransfusion testing is performed to ensure compatibility between the donor and recipient, which includes ABO and Rh typing and an antibody screening. In emergencies where there is no time to determine the recipient's blood type, O negative blood might be used as it is the universal donor type.

It is also essential that the drugs are formulated in an isotonic solution to maintain osmolarity and prevent hemolysis of red blood cells. The criticality of proper blood matching and monitoring during a transfusion cannot be overstated and serves as a life-saving procedure when conducted carefully and correctly.

User Hardik Patel
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