Which observation is most important during the first part of a packed red blood cell transfusion?
Correct answer: B. Remain with the patient and observe for an early reaction
- A. Measure the patient's weight after one hour
- B. Remain with the patient and observe for an early reaction
- C. Ask the patient to walk to assess tolerance
- D. Restrict all oral fluids until transfusion ends
Explanation
Serious transfusion reactions can begin soon after the transfusion starts, so the nurse remains with the patient and observes closely, including vital signs and symptoms. Weight, ambulation and blanket fluid restriction do not provide early reaction surveillance.
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About IV Fluids and Blood Transfusion
IV therapy covers crystalloid and colloid fluids, electrolyte replacement, maintenance and resuscitation fluids, infusion equipment and complications such as infiltration, phlebitis, fluid overload and electrolyte imbalance. Blood transfusion content includes compatibility, cross matching, administration precautions and recognition of haemolytic, febrile and allergic reactions, distinct from ordinary IV fluid reactions.
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