That's So Basic
What type of tubing must be used with blood product administration?
Y site tubing with filter
Signs of a transfusion reaction?
hives, SOB, fever, chills, CP, HA, flank pain, dark urine, anxiety
This is the first step if a transfusion reaction is suspected
Stop the infusion
Which nursing action helps prevent tracheostomy dislodgement?
Using two fingers of space under ties
Early sign of respiratory distress in a trach patient?
Restlessness, confusion, anxiety
Before starting a transfusion, this is assessed and documented to establish a baseline
VS and assessment
The most common type of transfusion reaction, often presenting with fever or chills
Febrile non-hemolytic
How soon must a blood transfusion be started after blood is received from the bank?
15 minutes
Which is the priority before performing tracheostomy suctioning?
Hyperoxigenate the pt
A patient’s trach dressing is soaked with serosanguinous drainage. The nurse should:
Change dressing using sterile technique
The only compatible fluid for blood transfusions.
0.9% NS
This type of reaction occurs when the body reacts to donor plasma proteins, often with itching or hives
Allergic reaction
How long does the RN stay with the patient after starting a transfusion?
15 minutes
What is the appropriate suction pressure for adults?
80-120 mm Hg
During suctioning, the catheter meets resistance. What should the nurse do?
Withdraw 1–2 cm before suctioning
This lab value is monitored to assess the effectiveness of red blood cell transfusions in anemic patients
Hemoglobin
A patient with a history of allergic reaction is to received blood. What medication may be ordered pre-transfusion?
Diphenhydramine
What patients need to be watched even more closely when receiving blood products?
very young, older adults, those with kidney and heart issues.
How long should the nurse wait between suction passes?
At least a minute and should pre-oxygenate pt again.
The nurse notes subcutaneous emphysema around the trach site. What is suspected?
Air leak
The maximum time blood can hang?
4 hours
This is a circulatory complication, characterized by difficulty breathing, crackles, and edema and often requires diuretics and oxygen therapy.
TACO
The patient has a transfusion reaction. What lab tests will be done?
blood draw and UA
The nurse notices dried secretions around the stoma. What is best practice?
Cleanse with 0.9% NS and then possibly with peroxide if the secretions can't be cleaned with saline alone.
During trach care, the patient begins coughing violently. What should the nurse do?
Stop the procedure and stabilize the trach.