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
3Obtain baseline vital signs and document them
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.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority action in the blood transfusion procedure. The core principle is Key Point!Patient Safety. A blood transfusion is a high-risk procedure where errors can lead to fatal transfusion reactions. The nursing process dictates that before any implementation (administering the product), a thorough and accurate Assessment and verification must occur to ensure the right product is given to the right patient.
Answer Rationale: The first and most critical step is two-nurse verification. This involves checking the patient's identity using two unique identifiers (e.g., name and medical record number) and meticulously matching the blood product's compatibility information (blood type, Rh factor, unit number, and expiration date) against the physician's order and the patient's identification. This step is mandated by hospital policy and accrediting bodies (like The Joint Commission) as the primary safeguard against ABO incompatibility reactions, which are life-threatening.
Distractor Analysis:
Watch out for confusion! While all other options are essential components of the transfusion process, they are not the first action.
Option 2 (Prime tubing): This is a preparatory step done after verification and before connecting the blood to the patient. Priming with normal saline (0.9% Sodium Chloride) prevents hemolysis of red blood cells.
Option 3 (Obtain baseline vitals): This is a crucial assessment step but occurs after verification. Baseline vital signs (temperature, blood pressure, heart rate, respiratory rate) are needed to compare against during the transfusion to detect early signs of a reaction.
Option 4 (Start an IV catheter): This should have been completed before the blood product arrives at the bedside. A patent IV line (typically an 18-gauge or larger catheter) is a prerequisite for transfusion, not the first action upon preparing to administer the unit.
Related Concepts: The sequence of safe blood administration follows a logical flow: 1) Verify with another RN, 2) Obtain baseline vitals, 3) Ensure patent IV access, 4) Prime tubing with normal saline, 5) Administer blood slowly for the first 15 minutes while monitoring closely, 6) Continue monitoring per protocol.
Concept Summary
Step
Purpose & Key Points
1. Two-Nurse Verification
Priority for safety. Check patient ID (2 identifiers) and match blood product details (type, Rh, unit #, exp. date) to the order and patient.
2. Baseline Assessment
Obtain and document vital signs. Assess for history of transfusion reactions.
3. IV Access Check
Ensure a patent, large-bore (18-gauge or larger) IV line is in place. Use only normal saline with blood products.
4. Administration & Monitoring
Start slowly (first 15 min), stay with patient. Monitor for reactions (fever, chills, itching, dyspnea, hypotension).
Side-by-Side Comparison!
Action
When It's the Priority
When It's Not the First Step
Two-Nurse Verification
Before administering ANY high-risk medication or blood product. It is the first safety check.
Never skip this step. It is always the initial priority for blood, chemotherapy, IV insulin, etc.
Obtaining Vital Signs
When assessing a patient's current status or detecting a change (e.g., suspected reaction during transfusion).
In the preparation phase, it comes after verification of the product and patient.
Initiating IV Access
When the patient has no IV access and needs emergent fluids or medications.
For a planned transfusion, IV access should be established well in advance of the product's arrival.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: An acute hemolytic transfusion reaction occurs when the recipient's antibodies attack the donor's red blood cells, causing rapid hemolysis. This can lead to disseminated intravascular coagulation (DIC), acute kidney injury, and shock.
Pharmacology/IV Therapy:Normal saline (0.9% NaCl) is the only solution compatible with blood products. Lactated Ringer's or solutions containing dextrose or calcium can cause clotting or hemolysis.
Procedure: Blood must be administered through a blood administration set with a built-in filter to trap clots and aggregates. It should be infused within 4 hours of leaving the blood bank.
Memory Tips
ABCs of Blood Admin:Always Buddy-check (two nurses) Carefully.
Order of Operations: Think Verify, Assess (vitals), Prime, Administer (VAPA).
IV Fluid Rule: "Blood is a Saline-only Friend." Never use anything but Normal Saline in the same line.
High-Frequency NCLEX Topics
Blood administration safety is a Core and High-Yield topic. The NCLEX-RN consistently tests:
Priority action (always verification first).
Signs and symptoms of transfusion reactions (fever, chills, back pain, dyspnea).
Nursing interventions for a suspected reaction (STOP the transfusion, keep the IV line open with normal saline, notify the physician, monitor vitals).
Compatible IV solutions (normal saline only).
Watch Out for Question Variations!
The same concept can be tested in different ways:
Priority during a reaction: "A patient develops hives and itching 10 minutes into a blood transfusion. What is the nurse's first action?" (Answer: Stop the transfusion.)
Selecting equipment: "Which IV solution should the nurse use to prime the blood administration tubing?" (Answer: 0.9% Normal Saline.)
Patient teaching: "A patient is to receive a blood transfusion. What should the nurse instruct the patient to report immediately?" (Answer: Chills, shortness of breath, itching, back pain.)
Nursing Clinical Practice GuideClinical Scenario: You are a nurse on a medical-surgical unit. Mr. Johnson, a 68-year-old with gastrointestinal bleeding and a hemoglobin of 7.2 g/dL, has an order for 1 unit of packed red blood cells (PRBCs). The blood bank has just delivered the unit to the floor.
Nursing Intervention Strategy:
Assessment & Verification (First!): Call another RN to the bedside. Together, using the patient's armband, verify Mr. Johnson's full name and medical record number. Then, compare the following on the blood unit tag to the physician's order and the patient's chart: blood type (A+), Rh factor (+), unit number, and expiration date. Both nurses sign the compatibility form.
Pre-Transfusion Assessment: Take and document Mr. Johnson's baseline vital signs: BP 128/76, HR 88, Temp 98.6°F (37°C), RR 16. Ask if he has ever had a transfusion reaction before.
IV Line Check: Confirm his peripheral IV in the right forearm is an 18-gauge catheter, patent, and without signs of infiltration or phlebitis. It is currently connected to a saline lock.
Preparation: Prime the blood administration tubing with normal saline. Attach the blood bag to the tubing.
Administration & Monitoring: Connect the tubing to Mr. Johnson's IV port. Start the transfusion slowly. Stay with him for the first 15 minutes (the most common time for acute reactions). Reassess vital signs 15 minutes after starting, then per hospital protocol (usually every hour). Educate him to report any chills, itching, shortness of breath, or back pain immediately.
Patient Safety and Precautions:
Contraindications/Cautions: Do not administer if the blood bag is leaking, has clots, or is discolored. Do not add any medications to the blood bag or infusion line.
Rate & Timing: Administer the unit over 2-4 hours as ordered. Do not let it hang for more than 4 hours due to risk of bacterial growth.
Key Monitoring: Watch for signs of fluid overload (crackles in lungs, dyspnea, increased BP) in elderly or cardiac patients, as PRBCs increase intravascular volume.
1. Flute line with NS. 2. Document volume infused, vitals, patient tolerance. 3. Monitor for delayed reactions.
Clears blood from IV line. Legal record and continuity of care. Some reactions occur hours later.
A Word from Your Senior Nurse
"Remember, when that unit of blood arrives, your most powerful tool is not the IV pump—it's your diligence in verification. That two-nurse check isn't just paperwork; it's a sacred ritual of patient safety. In the rush of a busy shift, it can be tempting to think 'I'm sure it's the right one,' but that's exactly when fatal mistakes happen. On the NCLEX and in real life, safety verification is always the priority. Think of it this way: you can't fix a reaction caused by the wrong blood, but you can absolutely prevent it by taking those 60 seconds to verify. That's the heart of being a safe, competent, and trusted nurse."
Two-Nurse Verification — A mandatory safety procedure where two qualified healthcare professionals independently check the patient's identity and the medication/blood product details against the order before administration.
Transfusion Reaction — An adverse response to a blood transfusion, ranging from mild (fever, urticaria) to severe, life-threatening (acute hemolytic, anaphylactic, TRALI).
Packed Red Blood Cells — A blood component prepared by removing most of the plasma from whole blood. It is used to increase the oxygen-carrying capacity in patients with anemia or blood loss.
Normal Saline (0.9% Sodium Chloride) — The only intravenous solution compatible with blood products. It is used to prime tubing, flush lines before and after transfusion, and keep the IV line open.
18-Gauge IV Catheter — A large-bore intravenous catheter often recommended for blood transfusions to allow for adequate flow rates and minimize hemolysis (damage to red blood cells).