A blood transfusion is prescribed for a client experiencing complications of sickle cell anemia with a hemoglobin level of 6 g/dL (60 g/L). Which of the following actions by the registered nurse are appropriate? Select all that apply. A)Asks another licensed nurse to verify client identifiers and blood before administration B)Delegates all vital sign measurements to the unlicensed assistive personnel C)Prepares O-negative blood for an AB-positive client D)Transfuses the blood over a 6-hour period of time E)Uses filtered tubing with normal saline to administer blood

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Blood transfusions are commonly administered to clients experiencing anemia or acute blood loss. To ensure client safety during blood administration, the nurse should: Verify two client identifiers (eg, name, medical record number, date of birth), the prescription, and the blood products with another licensed health care provider (Option A). Ensure that blood type and Rh type are compatible (Option C). An Rh-positive client can safely receive Rh-positive or Rh-negative blood. Administer the blood via filtered tubing with normal saline to prevent clumping in the tube and hemolysis of red blood cells (Option E). Monitor vital signs during transfusion per facility-specific protocol (eg, before transfusion, 15 minutes after transfusion begins, periodically). Transfuse blood products within 4 hours due to the risk for bacterial growth. (Option B) The nurse remains with the client for the first 15 minutes (ie, approximately 50 mL) of the transfusion and obtains vital signs directly to monitor for adverse reactions (eg, fever, chest pain). Delegating vital signs to unlicensed assistive personnel after the initial 15-30 minutes may be appropriate for stable clients. (Option D) Infusing blood over 6 hours increases the risk of bacterial contamination and hemolysis of the blood product. Educational objective: The nurse facilitates safe blood administration by verifying the prescription, blood type, and at least two client identifiers with another licensed health care provider; administering blood with normal saline; obtaining vital signs directly for the first 15 minutes (ie, approximately 50 mL of the transfusion); and transfusing blood within 4 hours.

A Blood Transfusion Is Prescribed for a Client Experiencing Complications