A nurse is preparing to administer a unit of packed red blood cells to a patient. Which action should the nurse perform first?
1Verify the patient's identity and blood product compatibility with another registered nurse✓ 정답
2Prime the blood administration tubing with normal saline solution
3Obtain baseline vital signs and document them in the chart
4Start an 18-gauge IV catheter in the patient's arm
해설
Two-nurse verification of patient identity and blood product compatibility is the priority action to prevent fatal transfusion reactions. Other steps like priming tubing or obtaining vitals are important but secondary to safety verification.
The first and most critical action before initiating a blood transfusion is to verify the patient's identity and blood product compatibility with another registered nurse. This process, known as double-checking, is a mandatory safety protocol designed to prevent life-threatening hemolytic transfusion reactions that occur when a patient receives incompatible blood. The systematic review by Zhao et al. highlights that medication administration errors, which include blood product errors, are a major cause of adverse events, and two-nurse double-checking is widely mandated to intercept such errors before they reach the patient [1]. This verification must be performed independently by two licensed professionals at the patient's bedside, confirming the patient's identity using two identifiers, the blood unit number, blood type, Rh factor, and expiration date against the patient's identification band and the provider's order. This step takes precedence over all other preparatory tasks because if a mismatch is identified, the entire process must be halted.
Why the Other Options are Secondary
The remaining options describe essential preparatory steps, but they are not the first action. The clinical reasoning follows a specific sequence dictated by patient safety priorities. Priming the tubing with normal saline (Option 2), obtaining baseline vital signs (Option 3), and ensuring functional IV access (Option 4) are all procedural steps that occur after the independent verification has been completed and documented. Performing these steps first would be inefficient and potentially dangerous if the blood product is subsequently found to be incompatible. For instance, priming the tubing or starting an IV would waste time and resources if the transfusion is canceled due to a failed identity or product check. The competency scale developed by Conceição et al. reinforces that adherence to safety protocols, including verification, is a core component of a nurse's global competence in transfusion care, underscoring that technical tasks like IV insertion are secondary to the cognitive and collaborative safety checks [2].
Pathophysiology and Clinical Safety Integration
The rationale for prioritizing independent double-checking is rooted in the pathophysiology of acute hemolytic transfusion reactions. If incompatible blood is infused, recipient antibodies attack the donor red blood cells, causing immediate intravascular hemolysis. This triggers a cascade of events including activation of the complement system, release of inflammatory cytokines, and potentially leading to disseminated intravascular coagulation (DIC), acute kidney injury, and cardiovascular collapse. The mortality rate for a major ABO incompatibility reaction is high. The systematic review notes that double-checking adherence is inconsistent and often omitted when clinical demands compete, which directly increases the risk of such catastrophic events [1]. Therefore, the NCLEX-RN exam consistently tests the concept that the independent verification step is the single most important barrier to prevent this error. The scale developed by Conceição et al. further validates that this behavior is a measurable and critical element of nursing competence, distinguishing a task-oriented approach from a safety-oriented one [2]. The nurse must first establish that the right blood is being given to the right patient before any physical preparation of the equipment or the patient begins.
References (research sources)
[1]
Nurses' Adherence to Double-Checking: A Systematic Review of Influencing Factors, Improvement Strategies, and Their Effectiveness.Meta-analysis/systematic reviewZhao J, Liu H, Shan A, Peng Y, Or CKL. (2026) · DOI: 10.1111/inr.70179
[2]
Global nursing competency scale in blood transfusion: development and psychometric validity.Research articleConceição BSD, Jacinto AF, Negri EC, Lima GK, Rebouças TO, Soares FMM. (2026) · DOI: 10.1186/s12912-026-04374-9
The first and non-negotiable step in administering packed red blood cells is the independent double-verification of the patient and the blood product. This is a high-risk, error-prone process that directly prevents fatal hemolytic reactions.
Step 1: Independent Double-Check
Two licensed professionals (e.g., RN and another RN) must perform the check simultaneously at the bedside.
Verify the patient's identity using two identifiers (name, date of birth) against the ID band and the blood product tag.
Confirm the blood unit number, blood type, Rh factor, and expiration date exactly match the patient's information and the provider's order.
If any discrepancy exists, the unit must not be hung and the blood bank must be notified immediately.
Step 2: Pre-Transfusion Assessment
Obtain a full set of baseline vital signs (temperature, pulse, respirations, blood pressure, oxygen saturation) within 30 minutes before starting the transfusion.
Assess the patient's respiratory and fluid volume status, including lung sounds and presence of edema.
Document all findings accurately in the patient's chart.
Step 3: IV Access & Equipment
Confirm a patent IV line with an appropriate gauge catheter (18-20 gauge is standard for adults to prevent hemolysis).
Prime the dedicated blood administration set with 0.9% normal saline only. Dextrose solutions cause hemolysis.
Have emergency equipment and medications (e.g., antihistamines, corticosteroids) readily available per facility protocol.
Critical Reminder: The two-nurse verification is the single most effective barrier against catastrophic transfusion error. Never delegate or skip this step, even in emergent situations.
Double-Checking — A mandatory safety protocol requiring two licensed professionals to independently verify patient identity and blood product compatibility at the bedside before a transfusion.
Hemolytic Transfusion Reaction — A life-threatening adverse event caused by the administration of incompatible blood, leading to the destruction of recipient red blood cells.