During blood transfusion, the most important nursing responsibility is?

Appeared in: AIIMS Rishikesh & Jodhpur NO - 2017

Explanation

The most important nursing responsibility is to run the blood slowly (e.g., 2 mL/min) for the first 15 minutes.
This practice is a critical safety measure because most life-threatening transfusion reactions (e.g., acute hemolytic reaction) occur early in the transfusion.
A slow initial rate ensures that only a small amount of blood is infused before a reaction can be detected, minimizing the severity of the reaction.
It allows the nurse to stay with the patient, closely monitor for signs of a reaction (chills, fever, hives, dyspnea), and intervene immediately by stopping the transfusion.

Option A: Drawing a blood sample is not a routine procedure before transfusing each unit of blood.
Option B: Warming blood is not a standard or routine procedure for all transfusions.
Option D: Using Ringer's Lactate (RL) solution with blood is contraindicated and dangerous.

Clinical Relevance

Nursing practice connection: Knowing Nursing Responsibilities in Blood Transfusion helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Patient safety is the paramount concern during blood administration. Starting the transfusion slowly is the single most effective way to mitigate the risk of a severe reaction.
A transfusion reaction is a medical emergency. The nurse's ability to recognize early signs and stop the infusion immediately can be life-saving.
What if? If the patient has a known history of febrile (non-hemolytic) transfusion reactions, the nurse should anticipate a provider's order for pre-medication with an antipyretic (like paracetamol) 30 minutes before starting the transfusion. The slow-start protocol remains essential.

How to Approach the Question

First, identify the core of the question: it asks for the 'most important' nursing responsibility during a blood transfusion. This indicates a priority-setting question.
Evaluate each option based on patient safety and potential for harm.
Option A (drawing sample) is a diagnostic step for a problem, not a primary preventative action.
Option B (warming blood) is a conditional intervention, not a universal 'most important' rule.
Option D (using RL) is incorrect and harmful. Immediately eliminate it.
Option C (slow initial rate) is a proactive safety measure designed to prevent the most immediate, life-threatening complications. This directly addresses the highest risk during the procedure.

Concept Tested & Keywords

QNoSUhewZavCqCRGuaeBKr

E6 Nursing Fundamentals Taylor p. 830-832

E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 75-77

Practise the full AIIMS Rishikesh & Jodhpur NO - 2017

Attempt every question from this paper in a timed mock, then review the full solution for each one.