SOLVED471

A nurse is caring for Flora Gannon who has a prescription for a transfusion of two units of packed red blood cells (PRBCs). The nurse obtains Mrs. Gannon’s vital signs prior to the start of the infusion and documents them on the Blood Transfusion Flowsheet. The nurse initiates the blood transfusion and remains at Mrs. Gannon’s bedside. Per facility policy, the nurse checks the client’s vital signs every 5 minutes for the first 15 minutes of the transfusion and documents them on the Blood Transfusion Flowsheet. Fifteen minutes after initiation of the transfusion, Mrs. Gannon’s vital signs are: B/P 116/68 mm Hg while supine Pulse 106/min – apical, via auscultation Respiratory rate 22/min via auscultation Temperature 38.3° C (101° F) – temporal SpO2 95% on room air Ms. Gannon reports chills, a headache, and feeling itchy and sweaty all over. The nurse discontinues the PRBC infusion, noting that 15 mL of the PRBCs have infused. The nurse initiates an infusion of 0.9% sodium chloride and prepares to notify the provider of the manifestations indicating a transfusion reaction. Practice documenting the following information in the client’s electronic health record in EHRT: Vital Signs at 15 minutes after initiation of the transfusion
SCIENCE
HEALTH SCIENCE
NURSING

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