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? 1. "a drop in blood pressure is expected during the transfusion and getting up to void may cause a fall." 2. "bedrest is required; therefore, voiding will prevent intermittent catheterization during the procedure." 3. "if a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed rbcs." 4. "the urine is collected and analyzed prior to starting the transfusion to assess the client's baseline results."

the correct answer is 3. "If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs."

Explanation:

The nurse should ask the patient 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 happens.