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NCLEX · General

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

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

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