Question

The oncology client has ordered two units of blood to be infused. What is the nurse’s highest priority? ? A. Obtain vital signs prior to transfusion ? B. Use an infusion pump for accuracy ? C. Infuse the blood slowly for the first 10–15 minutes ? D. Determine proper type and cross-match it

Short answer

A. Obtain vital signs prior to transfusion B. Use an infusion pump for accuracy C. Infuse the blood slowly for the first 10–15 minutes D. Determine proper type and cross-match it Answer: D. Determine proper type and cross-match it

Step-by-step solution

Analyze Choice A

Choice A: Obtain vital signs prior to transfusion. Obtaining vital signs is an essential step in ensuring patient safety and monitoring the patient's condition before, during, and after a transfusion. Vital signs, such as blood pressure, pulse, and temperature, can help detect adverse reactions or complications during the transfusion process.

Analyze Choice B

Choice B: Use an infusion pump for accuracy. An infusion pump can help maintain a consistent and accurate flow rate of the blood, but it is not the highest priority. While using an infusion pump can be beneficial, it does not take precedence over other safety measures, such as obtaining vital signs or ensuring the proper blood type and compatibility.

Analyze Choice C

Choice C: Infuse the blood slowly for the first 10–15 minutes. Infusing blood slowly during the initial phase of the transfusion (10-15 minutes) allows time for monitoring the patient for potential adverse reactions. While this step is essential, it can be argued that other safety measures, such as obtaining vital signs and ensuring proper blood compatibility, should be considered before the actual infusion process.

Analyze Choice D

Choice D: Determine proper type and cross-match it. One of the highest priorities during a blood transfusion is to ensure the proper blood type and compatibility. Transfusion reactions can occur when incompatible blood is given to a patient, leading to life-threatening complications and adverse reactions. Therefore, correctly identifying and cross-matching blood types are essential to guaranteeing patient safety and minimizing risks associated with transfusion.

Determine the Highest Priority

Based on analyzing all the choices, it's evident that Choice D: Determine proper type and cross-match it, holds the highest priority in ensuring patient safety during a blood transfusion. While the other steps are essential, ensuring the correct blood type and compatibility is paramount to avoid life-threatening complications during the transfusion process.

Key concepts

Cross-Matching Blood Types

The process of cross-matching blood types is crucial in preventing transfusion-related complications. It involves determining the patient's blood type and ensuring that the donor blood is compatible. Blood compatibility is essential because the wrong blood type can cause an immune response known as a transfusion reaction. This reaction can range from mild to life-threatening.

Cross-matching involves two important tests:

• **Blood Type Testing:** This identifies the presence of A, B, AB, or O antigens on the surface of red blood cells.
• **Antibody Screening:** This checks for antibodies in the recipient's plasma that might react with the donor blood.

This careful matching process helps ensure patient safety and minimizes risks during blood transfusions.

Vital Signs Monitoring

Monitoring vital signs is a foundational aspect of patient care during blood transfusions. It means watching the body's key indicators of health, such as blood pressure, pulse, temperature, and respiratory rate. This is crucial before, during, and after the transfusion.

By keeping a close eye on these markers, healthcare providers can quickly spot any signs of adverse reactions.

• **Before Transfusion:** Establish a baseline to compare any changes.
• **During Transfusion:** Detect early signs of transfusion reactions like fever, chills, or changes in blood pressure.
• **After Transfusion:** Ensure that any changes resolve and the patient returns to baseline values.

This continuous monitoring helps catch complications early and respond promptly to ensure patient safety.

Infusion Procedures

The infusion procedure is the method by which blood is delivered into the patient's bloodstream. Performing it correctly is crucial to minimize risks. At the start of a transfusion, it is advised to infuse slowly for the first 10-15 minutes. This allows the healthcare provider sufficient time to monitor for any immediate adverse reactions.

Key steps in the procedure include:

• **Preparation:** Verify patient identity and consent, check cross-matching results, and prepare equipment.
• **Initial Rate:** Start with a slower infusion rate to observe the patient closely for any reactions.
• **Monitoring:** Regularly check vital signs and adjust the infusion speed as needed.

Proper adherence to these procedures helps ensure that the transfusion is safe and effective.

Oncology Nursing Care

Oncology nursing care involves specialized support for patients undergoing cancer treatments, including blood transfusions. Nurses play a critical role in managing the complex needs of oncology patients, ensuring comfort, and closely monitoring their response to treatments including transfusions.

Key components of oncology nursing care include:

• **Assessment:** Regular monitoring of the patient’s physical and emotional state.
• **Education:** Informing patients and their families about treatment plans, including possible side effects.
• **Symptom Management:** Identifying and managing symptoms related to cancer or its treatment, such as nausea, pain, or fatigue.

Nurses collaborate with the oncology team to provide a holistic approach to care, which is critical in managing the challenges faced by cancer patients.