Fever, chills, flank or back pain, dark urine, or hypotension during transfusion signal a hemolytic reaction; stop it at once.
Before you read
Test yourself first: 5 questions
Question 1 of 5
A nurse is preparing to administer a unit of packed red blood cells. Which safety action is essential before starting the transfusion?
Answer: B. Verifying client identity and blood compatibility with a second licensed nurse at the bedside is the essential safety check that prevents fatal ABO-incompatibility reactions. The unit, the blood bank tag, and the client's identification band must all match. Blood must be administered with normal saline, not dextrose solutions, which cause hemolysis.
Question 2 of 5
A nurse is preparing to administer a unit of packed red blood cells. Which action is essential before starting the transfusion?
Answer: A. Two licensed personnel must verify the client identity, blood type, Rh, unit number, and expiration date against the blood bank record at the bedside. This double-check is the single most important step in preventing a fatal ABO-incompatibility hemolytic reaction.
Question 3 of 5
Within what time frame must a unit of blood be started after it is released from the blood bank, and over what maximum time should one unit infuse?
Answer: A. Blood must be started within 30 minutes of release from the blood bank to avoid bacterial growth from warming, and a single unit should infuse within 4 hours for the same reason. Units left out too long must be returned.
Question 4 of 5
A client receiving a blood transfusion suddenly reports chills, low back pain, and dark urine. What is the nurse's first action?
Answer: B. These signs suggest an acute hemolytic transfusion reaction. The immediate priority is to stop the transfusion at once to prevent further infusion of incompatible blood, then keep the IV line open with normal saline using new tubing and notify the provider and blood bank. Slowing the rate, giving antipyretics, or assessing first would delay stopping a life-threatening reaction.
Question 5 of 5
Before administering a blood transfusion, two nurses must verify:
Answer: B. Two qualified staff verify the client's identity (two identifiers) against the blood bank label, the blood type/Rh, the unit number, and the expiration — at the bedside — to prevent a fatal incompatible transfusion.
Keep the streak going with more questions like these, each with a full rationale.
What is abo blood compatibility?
Type O negative is the universal red cell donor, and type AB positive is the universal recipient. Correct patient and blood verification is one of the highest-priority safety checks in nursing.
Key points to remember
- Type O negative red cells are the universal donor and are used in emergencies before typing.
- Type AB positive is the universal recipient because the plasma has no A or B antibodies.
- Rh-negative patients should receive Rh-negative blood to prevent sensitization.
- Mismatched ABO blood causes an acute hemolytic transfusion reaction that can be fatal.
- Two qualified staff must verify the patient and blood product identity at the bedside.
- Blood is administered through a filtered set and only with normal saline.
Nursing priorities
- Verify patient identity, blood type, and unit number with a second nurse before starting.
- Stay with the patient and monitor vital signs closely during the first 15 minutes.
- Start the transfusion slowly and watch for early signs of a reaction.
- Stop the transfusion immediately at the first sign of a reaction and keep the IV open with saline.
- Use only normal saline with blood and never mix medications into the line.
Labs & values
Patient teaching
- Report any chills, itching, back pain, shortness of breath, or feeling unwell during a transfusion right away.
- Understand the reason for transfusion and that staff will check vital signs frequently for safety.
Red flags: report now
- Fever, chills, flank or back pain, dark urine, or hypotension during transfusion signal a hemolytic reaction; stop it at once.
- Never hang blood that does not exactly match the verified patient and order.
- Never infuse blood with any solution other than normal saline.
References
Clinical references for this topic
