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70.The nurse is staying with a patient who has been started on a blood transfusion. Which assessment should the nurse perform during a blood product infusion to detect a reaction?

a. Vital signs
b. Skin turgor
c. Bowel sounds
d. Pupil reactivity

1 Answer

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Final answer:

During a blood transfusion, a nurse should monitor the patient's a. vital signs to detect any potential reaction. Compatibility is vital to prevent a transfusion reaction, with type O blood used as a universal donor in emergencies.

Step-by-step explanation:

Assessment During Blood Transfusion

The nurse should perform an assessment of a. vital signs during a blood product infusion to detect a reaction. Monitoring a patient's vital signs is critical in identifying the onset of a potential transfusion reaction.

When a patient is receiving a transfusion, it is essential to ensure compatibility as an incorrect blood type can lead to a hemolytic transfusion reaction (HTR).

In the event of a severe emergency, where there is no time for blood typing, type O blood may be transfused because it's considered the universal donor type and is less likely to cause an immediate immune reaction.

If a patient's blood sample agglutinates with both anti-A and anti-B antibodies, it indicates that the patient has AB blood type. Agglutination with both anti-A and anti-B is a normal response for AB blood type individuals.

Finally, the cross-match assay is performed to ensure the compatibility of the donor's and recipient's blood types, which is critical in preventing adverse transfusion reactions.

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