RN Comprehensive Predictor 2023 Proctored Exam
A nurse is planning care for a client who is scheduled to receive a transfusion of packed RBCs. Which of the following actions should the nurse plan to take?
Explanation & Rationale
A. Ensure that the transfusion is completed within 6 hr: Incorrect. Blood transfusions should be completed within 4 hours to reduce the risk of bacterial contamination. B. Obtain venous access using a 22-gauge needle: Incorrect. A larger gauge (18-20) is preferred to prevent hemolysis and allow for faster administration. C. Store the unit of blood at room temperature for 1 hr prior to the infusion: Incorrect. Blood should remain refrigerated until it is ready to be transfused, and it should be started within 30 minutes of removal from refrigeration. D. Use a solution of 0.9% sodium chloride to flush the transfusion tubing: 0.9% sodium chloride is the only compatible solution with blood products to prevent hemolysis.
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