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NCLEX · Safety and Infection Control

A nurse is preparing to administer a blood transfusion. What is an essential safety step before starting the transfusion?

Reviewed by Jordan Morley, Editorial Lead at 247SimpleTests. Written by the 247SimpleTests Editorial Team from the official source material cited on every question.

Correct answer

Verify the blood product and client identity with a second qualified person (two-person verification of the right blood for the right client), and obtain baseline vital signs

  1. A Start it quickly without checks
  2. B Verify the blood product and client identity with a second qualified person (two-person verification of the right blood for the right client), and obtain baseline vital signs
  3. C Skip vital signs
  4. D Use the fastest infusion rate possible from the start

Why this is the answer

Before a BLOOD TRANSFUSION, essential safety steps include: TWO-PERSON VERIFICATION (two qualified staff independently check) of the client's identity (two identifiers), the blood product (type, Rh, unit number), the order, and the crossmatch — matching the RIGHT blood to the RIGHT client (a mismatch can be fatal); obtain BASELINE VITAL SIGNS; use proper tubing with a filter and normal saline only; verify consent; start SLOWLY and stay with the client for the first 15 minutes (when most reactions occur), monitoring closely. NCLEX safe care/safety. A TRANSFUSION REACTION (fever, chills, back pain, hypotension, dyspnea) requires STOPPING the transfusion immediately, keeping the IV open with saline, and notifying the provider/blood bank. Knowing the two-person verification and monitoring for transfusions is a critical, heavily tested NCLEX safety concept.
Source: NCLEX Safe Care — Blood Transfusion Safety

Practice more questions

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About this topic: Safety and Infection Control

Safety and infection control questions cover Standard and transmission-based precautions, isolation set-up, sterile technique, error prevention, restraints, and emergency and disaster response. This is one of 24 RN: Safe and Effective Care Environment questions on safety and infection control, each with a full explanation on a single study page.

New to this exam? Our NCLEX exam guide explains the format, scoring, and how to prepare.

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