Clinical Management of Acute Transfusion Reactions
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Questions and Answers

What is the first action a nurse should take if a blood reaction is suspected during a transfusion?

  • Continue monitoring the patient's vital signs
  • Notify the physician within 30 minutes
  • Stop the transfusion immediately (correct)
  • Change the Y-tubing infusion set to 0.9% normal saline

Why should the nurse not simply turn off the blood and turn on the 0.9% normal saline during a suspected blood reaction?

  • To save the remaining blood for future use
  • To avoid wastage of blood
  • To ensure proper mixing of blood with saline
  • To prevent infusion of mismatched blood remaining in the Y-tubing (correct)

What should the nurse do while observing signs and symptoms and monitoring vital signs during a suspected transfusion reaction?

  • Monitor vital signs as often as every five minutes (correct)
  • Administer emergency drugs without physician order
  • Prepare to discharge the patient from the hospital
  • Leave the patient unattended and inform the physician

Why is obtaining a urine specimen and sending it to the laboratory important during a suspected transfusion reaction?

<p>To determine the presence of hemoglobin as a result of RBC hemolysis (B)</p> Signup and view all the answers

What should the nurse do with the blood container, tubing, attached labels, and transfusion record during a suspected transfusion reaction?

<p>Save and return them to the laboratory (A)</p> Signup and view all the answers

What should the nurse prepare to administer in case of a suspected blood reaction during a transfusion?

<p>Emergency drugs such as antihistamines, vasopressors, fluids, and steroids as per physician order or protocol (D)</p> Signup and view all the answers

What is the most effective strategy to prevent acute transfusion reactions?

<p>Ensuring proper cross matching (A)</p> Signup and view all the answers

Why is it important to observe before, during, and after for transfusion regulation and allergic reactions?

<p>To identify any potential allergic reactions (D)</p> Signup and view all the answers

What is the significance of discarding administration tubing after four hours or after 2 units, or immediately after administering fractionated products?

<p>To avoid contamination with other medications or fluids (D)</p> Signup and view all the answers

Why should two RNs together check the label on the blood product against the patient’s ID number, blood group, and name?

<p>To ensure the blood is matched for ABO grouping and Rh factor (D)</p> Signup and view all the answers

What action can help in early detection of a transfusion reaction?

<p>Beginning the transfusion slowly (A)</p> Signup and view all the answers

Why is it essential to assess the patient’s history and allergies before a transfusion?

<p>To identify any potential allergic reactions (C)</p> Signup and view all the answers

Which of the following is NOT a recommended strategy to prevent acute transfusion reactions?

<p>Discarding administration tubing after four hours (A)</p> Signup and view all the answers

What is the significance of two RNs checking the label on the blood product against the patient’s ID number, blood group, and name?

<p>Ensuring correct blood transfusion (D)</p> Signup and view all the answers

Why is it important to begin the transfusion slowly?

<p>To allow for early detection of reaction (C)</p> Signup and view all the answers

What action can help in early detection of a transfusion reaction?

<p>Staying with the patient during the first 15 minutes (A)</p> Signup and view all the answers

Why is it essential to assess the patient’s history and allergies before a transfusion?

<p>To avoid allergic reactions (A)</p> Signup and view all the answers

What should be done with blood products to ensure proper delivery and prevent cross contamination?

<p>Deliver blood products in tubing with a filter (C)</p> Signup and view all the answers

Flashcards

Suspected blood reaction, first action?

Immediately stop the transfusion.

Why not just turn off & start saline?

To prevent mismatched blood still in the tubing from infusing.

Monitoring during suspected reaction?

Monitor vital signs every 5 minutes.

Urine specimen importance?

Checks for hemoglobin from red blood cell breakdown.

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Handling blood container (reaction)?

Save and return to the lab.

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Emergency drug preparation?

Antihistamines, vasopressors, etc., as ordered.

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Preventing transfusion reactions?

Accurate crossmatching is crucial.

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Importance of observation?

To catch any allergic reactions during or after.

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Discarding tubing timing?

Within 4 hours or after 2 units, or after fractionated products.

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Double-checking blood labels?

Ensuring ABO and Rh match with patient's info.

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Early Detection strategy?

Begin transfusion slowly.

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Patient history importance?

To identify potential allergies before transfusion.

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Bad transfusion prevention strategy?

Discarding tubing after 4 hours is NOT the only prevention.

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Blood product label checking?

Ensuring correct blood matches for transfusion.

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Why begin transfusion slowly?

Faster reactions are easier to detect early.

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Early reaction detection?

Stay with patient during first 15 minutes.

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Pre-transfusion patient assessment?

Assess patient's history and allergies.

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Safe blood product delivery?

Use tubing with a filter to prevent contamination.

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