Question

A nurse is educating a student nurse about blood transfusion and transfusion reactions. which of the following statements by the student nurse indicates the need for additional teaching? select all that apply.

a. "most common cause of fever during transfusion and transfusion reactions is hemolysis."
b. "transfusion related graft versus host disease occurs in immuno-suppressed patients."
c. "transfusion associated circulatory overload (taco) is more common in patients with baseline renal failure."
d. "it is important to ask the patient about history of previous blood transfusions."
e. "pre-medication with diphenhydramine and acetaminophen is always needed before transfusion."

Answer 1

The student nurse requires more teaching regarding the common causes of fever during a transfusion and the use of pre-medication before transfusions. Febrile non-hemolytic transfusion reaction is more common than hemolysis for causing fever, and pre-medication is not always necessary.

Step-by-step explanation:

When evaluating the statements by the student nurse regarding blood transfusion and transfusion reactions, two of them indicate a need for additional teaching.

1. Statement A: "Most common cause of fever during transfusion and transfusion reactions is hemolysis." This statement is incorrect as the most common cause of fever during a transfusion is actually a febrile non-hemolytic transfusion reaction (FNHTR), not hemolysis. Hemolysis can cause fever, but it is not the most common cause.
2. Statement E: "Pre-medication with diphenhydramine and acetaminophen is always needed before transfusion." This statement is also not accurate. Pre-medication may be used in certain situations to prevent allergic reactions or fever, but it is not still necessary for every transfusion.

The other statements show that the student nurse does have an understanding of some aspects of blood transfusions:

• Statement B correctly points out that transfusion-related graft-versus-host disease can occur in immuno-suppressed patients.
• Statement C is accurate in stating that transfusion-associated circulatory overload (TACO) is more common in patients with baseline renal failure.
• Statement D highlights the importance of knowing a patient's history of previous blood transfusions to prevent adverse reactions.