Page 2512 - Saunders Comprehensive Review For NCLEX-RN

bank.

▪ The recommended rate of infusion varies with the blood component being
transfused and depends on the client’s condition; generally, blood is infused as
quickly as the client’s condition allows (always follow agency guidelines and
prescriptions).
▪ Components containing few red blood cells (RBCs) and platelets may be infused
rapidly, but caution should be taken to avoid circulatory overload.
▪ The nurse should measure vital signs and assess lung sounds before the
transfusion and again after the first 15 minutes and every 30 minutes to 1 hour
(per agency policy) until 1 hour after the transfusion is completed.

Client Assessment

▪ Assess for any cultural or religious beliefs regarding blood transfusions.
▪ A Jehovah’s Witness cannot receive blood or blood products; this group believes
that receiving a blood transfusion has eternal consequences.

▪ Ensure that an informed consent has been obtained.
▪ Explain the procedure to the client and determine whether the client has ever
received a blood transfusion or experienced any previous reactions to blood
transfusions.
▪ Check the client’s vital signs; assess renal, circulatory, and respiratory status and
the client’s ability to tolerate intravenously administered fluids.
▪ If the client’s temperature is elevated, notify the primary health care provider
(PHCP) before beginning the transfusion; a fever may be a cause for delaying
the transfusion in addition to masking a possible symptom of an acute
transfusion reaction.

Blood Bank Precautions

▪ Blood will be released from the blood bank only to personnel specified by
agency policy.
▪ The name and identification number of the intended recipient must be provided
to the blood bank, and a documented permanent record of this information
must be maintained.
▪ Blood should be transported from the blood bank to only 1 client at a time to
prevent blood delivery to the wrong client.
▪ Only 1 unit of blood should be transported at a time, even if the client is
prescribed to have more than 1 unit transfused.

Client Identity and Compatibility

▪ Check the PHCP’s prescription for the administration of the blood product.
▪ The most critical phase of the transfusion is confirming product compatibility
and verifying client identity.

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