The nurse is administering blood. What should the nurse do to ...

[LaDunn]

The nurse is administering blood. What should the nurse do to detect a blood reaction as quickly as possible?
 
  a. Remain with the patient during the first 15 minutes.
  b. Transfuse the blood at 10 mL/min.
  c. Monitor vital signs q 1 hour.
  d. Transfuse blood at 50 gtt/min.

Question 2

While the nurse is administering an enema, the patient complains of some cramping. Which action should the nurse take next?
 
  a. Discontinue the procedure completely.
  b. Increase the height of the solution.
  c. Slow the rate of infusion.
  d. Have the patient roll into a supine position.

[bimper21]

Answer to Question 1

A
Remain with the patient during the first 15 minutes of a transfusion. Most transfusion reactions occur within the first 15 minutes of a transfusion. The initial flow rate during this time should be 2 mL/min, or 20 gtt/min. Initially infusing a small amount of blood component minimizes the volume of blood to which the patient is exposed, thereby minimizing the severity of a reaction. Monitor the patient's vital signs at 5 minutes, at 15 minutes, and every 30 minutes until 1 hour after transfusion or per agency policy. Frequent monitoring of vital signs will help to quickly alert the nurse to a transfusion reaction.

Answer to Question 2

A
If abdominal cramping develops, decrease the height of the enema bag and slow the rate of instillation. Changing the patient position will not be helpful. Sometimes, temporarily stopping the solution (taking a break) minimizes cramping.