Place the actions in order for safely starting one unit of packed red blood cells.
Ordered Response
Choose your responses, then check the answer.
Explanation
Complete consent, teaching, access, and baseline assessment before retrieving the unit so transfusion can begin promptly after issue. Inspect the unit, then perform the required bedside identity and compatibility verification. Start through approved blood tubing with compatible 0.9% sodium chloride at the prescribed slow initial rate. Remain with the client during the first 15 minutes because acute reactions often appear early; reassess before increasing the rate.
Correct sequence Prepare the client → retrieve and inspect → verify at bedside → start slowly → remain and reassess for 15 minutes.
Why this is correct Identity and compatibility errors can be catastrophic. Baseline findings allow early comparison, and close observation during the initial period supports rapid recognition and cessation if a reaction develops.
NCLEX decision rule Do not fetch blood until the client, access, consent, equipment, and nurse are ready to start.
References
1NCBI Nursing Advanced Skills: Administer Blood Products
2NCBI: Blood Transfusion
Pretransfusion through first 15 minutesThe adult client is hemodynamically stable and has no history requiring special product handling. Follow the prescription, blood-bank requirements, manufacturer instructions, and facility policy.
Compatibility Testing — Blood-bank testing and verification used to reduce immune incompatibility between a recipient and a donor unit.
Hemovigilance — Surveillance for adverse events across blood collection, issue, administration, and follow-up.
Acute Transfusion Reaction — A new adverse response that begins during or shortly after blood-component administration.