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Difficulty: MediumAccident, Error, and Injury Prevention

A registered nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client with symptomatic anemia. To prevent errors and ensure client safety, which of the following actions should the nurse take? (Select all that apply.)

  1. Verify the client's identity and the blood product information with a second registered nurse directly at the bedside.Answer
  2. B
    Prime the intravenous blood administration tubing with 5% Dextrose in Water (D5W) before initiating the transfusion.
  3. C
    Delegate the continuous monitoring of the client to the unlicensed assistive personnel (UAP) during the first 15 minutes of the infusion.
  4. Remain with the client and assess for signs of a transfusion reaction for the first 15 minutes of the infusion.Answer
  5. E
    Dispose of the empty blood bag and administration tubing in a standard trash receptacle once the transfusion is complete.
  6. Ensure the entire unit of packed red blood cells is infused within 4 hours of being issued from the blood bank.Answer

Answer

The correct actions are to verify the client and blood product with a second nurse at the bedside, remain with the client for the first 15 minutes of the infusion, and ensure the transfusion is completed within 4 hours.
The correct actions ensure safe blood administration. Verifying the blood product with a second nurse at the bedside prevents fatal ABO incompatibility errors. Remaining with the client for the first 15 minutes is critical because this is when severe hemolytic reactions most commonly occur. Finally, completing the transfusion within 4 hours is strictly necessary to prevent bacterial proliferation and subsequent septicemia.

Step-by-Step Solution

1
Identify the high-risk nature of the procedure.
Blood transfusions carry a high risk for sentinel events, requiring strict adherence to verification protocols.
To prevent ABO incompatibility and hemolytic reactions.
2
Determine appropriate delegation and assessment.
The registered nurse retains responsibility for the critical initial 15-minute assessment.
Unlicensed assistive personnel (UAPs) cannot perform initial clinical assessments or evaluate for adverse reactions.
3
Evaluate equipment compatibility and disposal procedures.
Use only 0.9% Normal Saline for priming and dispose of materials in biohazard containers.
To prevent cellular hemolysis and adhere to strict infection control and environmental safety standards.

Key Concept

Blood Transfusion Safety and Error Prevention
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Topics

Accident, Error, and Injury Prevention

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