NCLEX-PN® ExaminationPhysiological AdaptationEasy
A client admitted with a severe gastrointestinal bleed has a hemoglobin of 6.2 g/dL and is hypotensive. The nurse is preparing to administer 2 units of packed red blood cells (PRBCs). Which of the following is the most critical nursing action prior to initiating the transfusion?
- AInitiate a new intravenous line with a 22-gauge catheter.
- BAdminister a prescribed oral antipyretic to prevent fever.
- CVerify the client's identity and blood product information with another nurse.
- DObtain a complete medication history from the client.
Show answer & explanationAnswer & explanation
Correct answer: C. Verify the client's identity and blood product information with another nurse.
Verifying the client's identity and matching it with the blood product information with another licensed nurse is the most critical step to prevent a fatal transfusion reaction due to ABO incompatibility. This double-check prevents wrong-blood-to-wrong-patient errors.
Why the other options are wrong
- A. A 22-gauge catheter is generally too small for rapid transfusion of PRBCs, which ideally requires an 18- or 20-gauge catheter. This is an important consideration but not the most critical 'prior to initiating' safety check.
- B. An antipyretic might be given to prevent febrile non-hemolytic reactions, but it's not as critical as ensuring blood compatibility.
- D. Obtaining a medication history is important for overall care but not the most critical immediate action before initiating a blood transfusion.
Blood Transfusion Safety Check
The most critical safety check before administering a blood transfusion is the two-person verification of client identity and blood product compatibility to prevent ABO incompatibility reactions.
- ABO incompatibility can lead to severe, life-threatening hemolytic reactions.
- Two-person verification is a mandatory safety protocol.
- Check blood type, Rh factor, unit number, expiration date, and client's name/DOB.
Memory trick: Two nurses check, right blood, right patient, no regret!