Question

A nurse is caring for a client who is scheduled to receive a unit of packed red blood cells. Which is an appropriate action by the nurse during the administration of the infusion?

A
Limit the infusion time to a maximum of four hours Correct Answer (Blank)
B
Slow the rate of infusion if the client develops a fever or chills
C
Store the packed red cells in the unit refrigerator while starting an intravenous (IV) line
D
Assess vital signs every 15 minutes for the duration of the infusion

Answer 1

An appropriate nursing action during a red blood cell transfusion is (A) to limit the infusion to a four-hour maximum, slow the infusion if the patient develops a fever or chills, and assess vital signs every 15 minutes during the infusion.

Step-by-step explanation:

When a nurse is caring for a client scheduled to receive a unit of packed red blood cells, there are specific protocols to follow to ensure patient safety and efficacy of the transfusion. An appropriate action during the administration of the infusion would be to limit the infusion time to a maximum of four hours. The transfusion must be completed within this time frame to minimize the risk of bacterial contamination.

Additionally, if the client develops a fever or chills, it is crucial to slow the rate of infusion as this may indicate an adverse reaction, and further assessment is required. Packed red cells should not be stored in the unit refrigerator while starting an IV line; instead, they should remain in proper storage until needed to maintain the correct temperature. Lastly, assessing vital signs every 15 minutes for the duration of the infusion is crucial for monitoring the client's response to the transfusion and for early detection of any potential adverse reactions.