A nurse is preparing to administer 1 unit of PRBCs. Which se… | MyMerci
Adverse Effects/Contraindications/InteractionsPPT
Question
A nurse is preparing to administer 1 unit of PRBCs. Which set of pre-administration practices is essential to prevent a fatal hemolytic reaction?
1Mix PRBCs with D5W to slow infusion
2Two-RN bedside verification of client identity (two identifiers), product ABO/Rh, unit number, expiration, and crossmatch — using NS only, no other fluids in the line; start slowly and stay with the client for the first 15 minutes✓ Correct answer
3One nurse silently checks the label
4Administer all units within 1 hour regardless of monitoring
Explanation
Correct (2): Two-RN bedside verification required to prevent ABO incompatibility. Match: client two identifiers, blood product ABO/Rh, unit number, expiration, crossmatch results. Use NS ONLY (D5W causes hemolysis; LR contains Ca that clots). Start slowly, stay with client first 15 min — most severe reactions occur within 15 min. Each unit must be completed within 4 hours. (1,3,4) Dangerous.
In-depth explanation
Memory Tip Transfusion 4 rules = "2-RN check, NS only, Start slow + watch 15 min, 4-hr max." Vitals pre, 15 min, 1 hr, end. Stop and assess for any reaction.
Clinical scenario
Scenario Adult with symptomatic anemia ordered for 1 unit PRBCs. Unit retrieved from blood bank.