A doctor orders one unit of whole blood for a patient after intestinal surgery. What is the important nursing responsibility when administering blood?

Appeared in: ISRO 2024

Explanation

The most critical period for detecting a severe transfusion reaction is the first 5 to 15 minutes of the infusion.
Starting the transfusion at a slow rate (e.g., 2 mL/min) ensures that if an acute reaction occurs, the volume of incompatible blood the patient receives is minimized.
This practice allows the nurse to stay with the patient, observe for signs of a reaction (like flushing, dyspnea, itching, or chills), and intervene immediately.
After the initial 15-minute observation period with no adverse effects, the infusion rate can be increased to complete the transfusion within the prescribed time frame (usually under 4 hours).

Option A: Dextrose solutions are hypotonic and cause red blood cells to hemolyze (break down). Using them with blood products is contraindicated and dangerous.
Option B: Blood is not routinely warmed for a standard, single-unit transfusion. Uncontrolled warming can damage red blood cells.
Option C: A new blood sample is not required before transfusing each individual unit of blood.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Nursing Responsibilities in Blood Transfusion Administration in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Patient safety is the absolute priority during a blood transfusion. The nurse is the final safeguard to prevent a life-threatening transfusion reaction.
Recognizing and responding to a transfusion reaction is a critical nursing skill. Immediately stopping the transfusion and maintaining IV access with normal saline can be life-saving.
What if the patient has a known history of febrile (non-hemolytic) transfusion reactions? The healthcare provider may order premedication with an antipyretic (like paracetamol) 30 minutes before the transfusion to reduce the risk of fever.

How to Approach the Question

First, identify the core of the question: it asks for the most 'important' nursing responsibility during blood administration. This implies a priority-setting question.
Evaluate each option based on patient safety principles.
Option A: Recall fluid compatibility. Dextrose and blood are incompatible and cause hemolysis. This is an incorrect and unsafe action.
Option B: Consider if this is a routine or special action. Warming blood is not standard for a single unit and requires special equipment. This is not the most important general responsibility.
Option C: Think about the lab testing protocol. Crossmatching is done before the transfusion series starts, not before every single unit. This is an incorrect frequency.
Option D: Analyze the rationale. The initial phase of a transfusion is the highest risk period for severe reactions. Starting slowly is a key safety measure to minimize harm if a reaction occurs. This directly addresses the greatest immediate risk to the patient, making it the most important responsibility.

Concept Tested & Keywords

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E6 Nursing Fundamentals Taylor p. 830-832

E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 75-77

Practise the full ISRO 2024

Attempt every question from this paper in a timed mock, then review the full solution for each one.