The nurse is preparing to administer a unit of packed red blood cells to a client whose hemoglobin is 7 g/dL (70 g/L). What tasks can the nurse delegate to unlicensed assistive personnel? Select all that apply.

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The registered nurse (RN) is responsible for most of the care rendered to a client during a blood transfusion as this is considered a high-acuity procedure requiring a high level of nursing assessment and judgment. Based on the individual state or provincial practice act and institutional policy, the RN may have assistance from a licensed practical nurse with checking blood products, verifying client identification, and monitoring the blood transfusion rate. Unlicensed assistive personnel (UAP) can obtain the blood product from the blood bank and courier it to the floor where the RN will verify the blood product with another nurse (Option E). UAP can also take vital signs before the transfusion begins and any time after the first 15 minutes of infusion (Options B and C). (Option A) Only nurses are able to verify blood product and client identification for blood transfusion procedures. (Option D) It is the responsibility of the RN to stay with the client during the first 15 minutes of the transfusion, monitor client response, and measure vital signs. A transfusion reaction is most likely to occur during this time. However, the RN may delegate measurement of vital signs after the first 15 minutes. Educational objective: After the registered nurse has initiated and monitored the client for the first 15 minutes of a blood transfusion, measurement of vital signs may be delegated to unlicensed assistive personnel, who may also obtain the blood product from the blood bank.

The Nurse Is Preparing to Administer a Unit of Packed