NCLEX-PN

involving two nurses who cross-check the blood, order, and client's identity using at least two unique identifiers. ●​ Verification Steps : The two nurses must cross-check various details, including the blood against the order, the client's identity, the client's blood type against the transfusion type, the blood's expiration date, and the client's identification against the blood product number. Additionally, visually inspect the blood for any unusual characteristics like color, precipitates, or clumping. ●​ Complete Orders : Ensure that the order for blood or blood components is complete and specific, detailing exactly what will be administered. The client's informed consent for the transfusion is also mandatory. ●​ IV Catheter and Infusion Set : Use an 18-gauge intravenous catheter , and administer the blood with a Y infusion set designed for blood and blood product administration. Normal saline is the recommended solution for compatibility. Other incompatible solutions, such as Ringer's lactate or dextrose , should not be used. If a blood filter is employed, verify its suitability for the specific blood product. ●​ Timely Initiation : Blood should not remain in the client care area for more than 30 minutes, so be prepared to start the transfusion shortly after its delivery to the client care area. ●​ Baseline Vital Signs : Before initiating the transfusion, record baseline vital signs. During the first 15 minutes , remain with and closely monitor the client as transfusions are typically associated with the most severe reactions and complications during this period. Transfusions must be completed within 4 hours . ●​ Authorized Personnel : Only registered nurses and licensed practical nurses are qualified to initiate, monitor, and maintain blood transfusions. These responsibilities cannot be delegated to unlicensed assistive nursing staff members. Facility-specific policies may further restrict blood transfusions to registered nurses, so adherence to these policies is crucial. Always consult the facility's policies and procedures regarding the administration of blood and blood products to ensure full compliance. Ensuring Adequate Venous Access for Red Blood Cell and Blood Product Administration For the safe administration of red blood cells and blood products, the nurse must ensure the following: ●​ Venous Line Patency : Confirm that the intravenous (IV) line is clear and patent. Any blockages or obstructions in the line must be addressed promptly to prevent interruptions in the transfusion. ●​ Appropriate Catheter Size : Utilize an 18 or 20-gauge catheter to ensure adequate venous access. These larger gauge catheters are preferred for blood transfusions to facilitate the smooth flow of blood products and reduce the risk of hemolysis or clotting within the catheter.

399

© 2025 ACHIEVE ULTIMATE CREDIT-BY-EXAM GUIDE | NCLEX-PN ​

​

​

​

​