An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of packed red blood cells (RBCs) to be hung over 3 hours. Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion?

Question

An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of packed red blood cells (RBCs) to be hung over 3 hours.  Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion?

Quizplus · Accepted Answer

The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibility. Early signs of a hemolytic reaction include red urine, fever, and hypotension; late signs include disseminated intravascular coagulation and hypovolemic shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs. Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion has started (Option D). (Options A and B) Hypotension is a sign of a transfusion reaction and is not expected. Bedrest is not required, but the client should be assisted if out of bed during a transfusion to prevent falls. Educational objective: An acute hemolytic transfusion reaction is a life-threatening reaction caused primarily by blood incompatibility. If it occurs, the transfusion should be stopped and a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. Asking the client to void prior to starting the transfusion helps ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion.

An Experienced Nurse Precepts a Graduate Nurse Caring for a Hospitalized