Question

The nurse who just came on duty observes that the client, whose blood type is AB negative, is receiving a transfusion with type O negative packed red blood cells. What is the nurse's best first action?

A. Call the blood bank.
B. Take and record the client's vital signs.
C. Stop the transfusion and keep the IV open.
D. Document the observation as the only action.

Answer 1

The nurse should first take and record the client's vital signs when observing the client with AB-negative blood receiving a transfusion of O-negative packed red blood cells, as type O-negative is considered the universal donor and can be safely given to any recipient.

Step-by-step explanation:

The nurse observing a client with blood type AB negative receiving type O negative packed red blood cells should not be alarmed immediately because type O negative red blood cells can be transfused to any recipient without fear of ABO transfusion reactions. This is because type O blood cells do not carry A or B antigens, preventing an immune response from recipients with different blood types.

It is good practice to monitor the client's condition when receiving a blood transfusion, even if type O-negative blood is considered the universal donor. Therefore, the nurse's best first action would be to take and record the client's vital signs to monitor for any adverse reactions to the transfusion. In the event of any signs indicating a transfusion reaction, the nurse should then follow the protocol which typically involves stopping the transfusion, maintaining the IV access with saline, and notifying the physician.