A nurse is preparing to administer a unit of packed red bloo… | 마이메르시 MyMerci
Fundamentals
문제

A nurse is preparing to administer a unit of packed red blood cells to a patient with severe anemia. Which action should the nurse take first before starting the blood transfusion?

해설
Patient and blood product verification with another nurse is the priority to prevent fatal transfusion reactions from ABO incompatibility. Other actions like vital signs or consent are important but secondary.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question tests the critical safety protocol for initiating a blood transfusion. The core principle is Key Point! preventing life-threatening transfusion reactions, the most dangerous of which is an acute hemolytic reaction caused by ABO incompatibility. The single most effective way to prevent this is through a rigorous, two-person verification process at the patient's bedside immediately before administration.

Answer Rationale: The correct answer is ④ Verify patient identification and blood product compatibility with another nurse. This action is the absolute Key Point! first step because it directly addresses the greatest immediate risk to patient safety. The verification process includes checking the patient's identification using two unique identifiers (e.g., name and medical record number), matching the blood product label (unit number, blood type, Rh factor, expiration date) against the patient's blood bank paperwork, and confirming compatibility. This step is non-negotiable and must be completed immediately before the blood is hung.

Distractor Analysis:
• ① Check the patient's vital signs and document baseline measurements: While this is a required action, it is not the first action. Baseline vital signs are taken after the blood product is verified and brought to the bedside but before the transfusion is started. It is part of the pre-transfusion assessment, not the initial safety check.
• ② Ensure that informed consent has been obtained from the patient: Informed consent is a legal and ethical prerequisite that should be completed well before the day of the transfusion, during the patient education process. On the day of administration, the nurse confirms the patient's understanding, but verification of the blood product itself takes precedence at the moment of administration.
• ③ Prime the blood administration tubing with normal saline solution: This is a preparatory step but is done after the blood product has been verified. The tubing must be primed with normal saline (0.9% NaCl) to prevent hemolysis of red blood cells and to ensure the line is ready. It is not the priority safety check.

Related Concepts: This question integrates the nursing process (prioritization), patient safety (The Joint Commission's National Patient Safety Goals, specifically NPSG.01.01.01 for patient identification), and the pathophysiology of transfusion reactions. Understanding the sequence of steps is crucial for both NCLEX and clinical practice. Concept Summary • Priority Action: Two-nurse verification at bedside is ALWAYS first. • Pre-Transfusion Sequence: Verify → Obtain Baseline VS → Educate/Confirm Consent → Prime Line with NS → Start Transfusion. • Safety Goal: Prevent acute hemolytic reaction (ABO incompatibility). • Key Monitoring: Vital signs at baseline, 15 min after start, then per protocol (e.g., hourly). Side-by-Side Comparison!
StepTiming & RationaleCommon Error
Verify with another nurseFIRST, at bedside. Directly prevents fatal error.Doing it in the medication room or alone.
Check baseline vital signsAfter verification, before starting. Establishes a baseline for detecting a reaction.Taking VS as the very first action before the blood is even checked.
Prime tubing with Normal SalineAfter verification. Prepares equipment; NS is the only compatible solution.Priming with Lactated Ringer's or other IV fluids (causes hemolysis).
Anatomy, Physiology & Pharmacology Points • Pathophysiology of Reaction: ABO incompatibility causes donor RBCs to be attacked by the recipient's antibodies (IgM), leading to intravascular hemolysis, DIC (Disseminated Intravascular Coagulation), acute kidney injury, and shock. • IV Fluid Compatibility: Only 0.9% Normal Saline (NS) is used with blood products. Solutions containing calcium (e.g., LR) or dextrose can cause clotting or hemolysis. • Time Limits: A unit of PRBCs (Packed Red Blood Cells) must be transfused within 4 hours of leaving controlled storage to prevent bacterial growth. Memory Tips • Mnemonic: V-BE-SAFE for transfusion priority: Verify (with 2 nurses), Baseline VS, Educate/Equipment (prime with NS), Start, Assess frequently, Finish on time (within 4 hrs), Evaluate post-transfusion. • Think: "Check the blood before it touches the patient." The verification is the gatekeeper. High-Frequency NCLEX Topics This is a High Yield priority question. NCLEX loves to test the first or priority action in a sequence, especially for high-risk procedures like blood administration. You must know that verification trumps all other preparatory steps. Watch Out for Question Variations! • Variation 1: "The nurse has verified the blood product with another nurse. What is the next action?" → Answer: Obtain and document baseline vital signs. • Variation 2: "A patient develops chills, fever, and low back pain 10 minutes into a transfusion. What is the nurse's priority action?" → Answer: Stop the transfusion immediately, keep the IV line open with normal saline, and notify the physician. (This tests recognition and response to a transfusion reaction).

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are assigned to Mr. Johnson, a 68-year-old with a history of GI bleed, whose hemoglobin is 7.2 g/dL (Normal: 13.5-17.5 g/dL). The physician has ordered 1 unit of PRBCs. The blood bank has delivered the unit to the floor.

Nursing Intervention Strategy: 1. Safety Verification (Two-Nurse Check): With another RN or LPN, go to the patient's bedside. Scan the patient's armband and have the patient state their full name and date of birth. Compare this to the blood requisition form and the label on the blood bag. Both nurses must sign the form. 2. Pre-Transfusion Assessment: Assess the patient's understanding of the procedure, check for a history of transfusion reactions, and auscultate lung sounds (to establish a baseline for fluid overload risk). Obtain and document baseline vital signs: Temperature, Pulse, Respiration, Blood Pressure, and Oxygen Saturation. 3. Line Preparation: Ensure the patient has a patent IV line with an 18-gauge or larger catheter (for rapid flow if needed). Prime the Y-type blood administration set with 0.9% Normal Saline. 4. Initiation & Monitoring: Start the transfusion slowly (e.g., 2 mL/min or per protocol) for the first 15 minutes while staying with the patient. Re-assess vital signs at 15 minutes. If no reaction, increase the rate to complete the infusion within the ordered time (but not exceeding 4 hours). Continue to monitor per hospital policy (often hourly).

Patient Safety and Precautions: • Watch out for confusion! Never add medications to a blood product or transfuse through the same line with medication. • Use only 0.9% Normal Saline to prime the line or flush. Other solutions cause clotting or hemolysis. • If a reaction is suspected: STOP THE TRANSFUSION. Keep the IV line open with NS. Notify the physician and blood bank immediately. Send the blood bag, tubing, and a new blood sample from the patient to the lab. Nursing Procedure & Medication Flow Step-by-Step for Blood Transfusion: 1. Verify order and consent (should already be done). 2. Two-nurse verification at bedside (FIRST STEP upon receiving the blood). 3. Obtain baseline VS and perform physical assessment. 4. Prime tubing with NS, connect to patient's IV line. 5. Start transfusion slowly (stay for first 15 min). 6. Re-assess VS at 15 min, then per protocol (e.g., hourly). 7. Monitor for reactions: Fever, chills, itching, hives, dyspnea, chest/back pain, hypotension. 8. After completion, flush line with NS and document volume infused, patient tolerance, and post-transfusion VS. 9. Dispose of the blood bag and tubing in the biohazard container. A Word from Your Senior Nurse "Blood is not just another IV fluid—it's a living tissue transplant. A single verification error can be fatal. In the rush of a busy shift, this two-nurse check is your sacred pause, your moment to be 100% certain. On the NCLEX, they are testing your ability to identify the step that is the ultimate safety barrier. In real life, this habit saves lives. Always verify, every time, no exceptions."

핵심 개념

  • Packed Red Blood Cells — A blood component prepared by removing most of the plasma from whole blood. Used to increase oxygen-carrying capacity in patients with anemia or blood loss.
  • Acute Hemolytic Transfusion Reaction — A severe, often fatal reaction caused by the infusion of ABO-incompatible blood. Symptoms include fever, chills, low back pain, hypotension, hemoglobinuria, and can lead to DIC and renal failure.
  • Two-Patient Identifier — A safety standard requiring the use of two distinct methods (e.g., name and date of birth or medical record number) to confirm a patient's identity before administering care, including blood products.
  • Y-Type Blood Administration Set — Special IV tubing with a Y-connector, allowing the line to be primed and flushed with normal saline (one branch) while the blood product (other branch) is infused. It includes a filter to trap clots.
  • Informed Consent — The process of communication between a patient and provider that results in the patient's authorization or agreement to undergo a specific procedure (like a transfusion), after understanding the risks, benefits, and alternatives.

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