Question

A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement?

a) Administer the blood transfusion through a central line
b) Infuse the blood slowly to monitor for adverse reactions
c) Assess vital signs before and after the first unit
d) Warm the blood to body temperature before administration

Answer 1

The most important intervention for a nurse administering a rapid transfusion of packed RBCs to a client with acute hemorrhagic anemia is to assess vital signs before and after the first unit to monitor for adverse reactions. Compatibility of blood types is essential to prevent complications.

Step-by-step explanation:

The most important intervention for a nurse to implement when a client with acute hemorrhagic anemia is to receive four units of packed RBCs as rapidly as possible is to assess vital signs before and after the first unit. Monitoring the patient closely for adverse reactions, such as a hemolytic transfusion reaction, is critical during a rapid transfusion. While warming the blood, utilizing a central line if available, and infusing blood slowly are all valuable considerations, the priority in this situation, where rapid administration is indicated, is vigilant monitoring of the patient's response to the transfusion.

Assessing vital signs is crucial for detecting any immediate adverse reactions and ensuring the patient's safety. Ensuring compatibility of the blood type through pretransfusion testing is also essential to avoid life-threatening complications. In emergency situations where the blood type cannot be determined, type O negative blood is often used as it is considered the universal donor and minimizes the potential for adverse reactions.