During blood transfusion a nurse should look for all the following except?

IGNOU Post B. SC. Nursing entrance -2021

Medical & Surgical Nursing

Easy

Appeared in: IGNOU Post B. SC. Nursing entrance -2021

Explanation

Blood products are stored at a specific cool temperature (typically 1-6°C) to preserve red blood cells and prevent bacterial growth.
Further cooling of the blood before administration is never indicated and can be harmful to the patient.
Administering overly cold blood can lead to hypothermia and potentially cause cardiac dysrhythmias.
In certain clinical situations, such as massive or rapid transfusions, blood is actively warmed using a specialized blood-warming device, which is the opposite of cooling.

Option A: This is a critical and mandatory safety procedure. Failure to correctly identify the donor and recipient blood types can lead to a life-threatening hemolytic transfusion reaction.
Option B: This is a standard nursing intervention. The nurse must regularly assess the IV site for signs of infiltration (swelling, coolness, pain) to ensure the blood is infusing correctly into the vein and not into the surrounding tissue.
Option D: This is an essential monitoring task. Pain (especially in the back, chest, or flank) and dyspnea are key signs of a potential transfusion reaction, such as a hemolytic reaction or circulatory overload.

Clinical Relevance

Nursing practice connection: Knowing Nursing responsibilities and safety protocols during blood transfusion helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Adherence to blood transfusion protocols is a cornerstone of patient safety. Errors can have fatal consequences.
The nurse is the final safeguard in preventing transfusion errors. The 'two-person verification' process at the bedside is a critical safety net.
What if? If a patient receiving a rapid, large-volume transfusion starts shivering uncontrollably, the nurse should not just provide a blanket but also immediately check if a blood warmer is in use. Rapid infusion of cold blood is a primary cause of transfusion-associated hypothermia, and a warmer is essential in this scenario.

How to Approach the Question

First, identify that the question uses the word 'except'. This means you are looking for the option that is an incorrect action or statement.
Evaluate each option based on standard nursing protocols for blood transfusion.
Option A: Is verifying blood type a standard procedure? Yes, it's critical.
Option B: Is checking the IV site a standard procedure? Yes, it's necessary.
Option C: Is cooling the blood a standard procedure? No, blood is stored cool and either allowed to warm to room temp or actively warmed, never cooled further.
Option D: Is watching for pain and dyspnea a standard procedure? Yes, it's vital for monitoring reactions.

Concept Tested & Keywords

Concept Tested: Nursing responsibilities and safety protocols during blood transfusion.
Stem keywords: blood transfusion, nurse, look for
Lead-in keywords: except
Negative lead-in flag: The question asks for the exception, meaning the action a nurse should NOT perform.

Q9ylk-Tan81dAZOC2EmRyW

E6 Nursing Fundamentals Taylor pp. 830-832, 808-810

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