Which of the following is the most appropriate action of a nurse while transfusing blood to a patient?

Appeared in: BTSC Staff Nurse 1 August-2025

Explanation

Changing the blood administration set after each unit, or at least every 4 hours, is a critical infection control measure.
This practice prevents the proliferation of bacteria in the tubing and filter, which can occur when blood is at room temperature, reducing the risk of septicemia.
The filter within the administration set is designed to remove particulate matter and can become clogged with microaggregates from the first unit, potentially slowing or stopping the flow of subsequent units.

Option A: Dextrose solutions are hypotonic and cause red blood cells to clump (agglutinate) and burst (hemolysis), which can be life-threatening.
Option B: The transfusion must be started slowly (e.g., approximately 2 mL/min) for the first 15 minutes. The nurse must remain with the patient to monitor for early signs of a transfusion reaction.
Option D: Blood must be fully infused within 4 hours of being removed from controlled refrigeration. An infusion time of 6-8 hours significantly increases the risk of bacterial growth and sepsis.

Clinical Relevance

Nursing practice connection: Use the key finding related to Safe Nursing Practices for Blood Transfusion to guide bedside assessment, documentation, and the next nursing action.
Adhering to strict transfusion protocols is a core nursing responsibility that directly prevents life-threatening complications like sepsis, acute hemolytic reactions, and fluid overload.
A transfusion reaction is a medical emergency. The nurse's first action is to immediately stop the transfusion, but keep the IV line open with normal saline to manage potential complications.
What if? The patient needs two units of blood transfused consecutively. The nurse should use a new administration set for the second unit to minimize infection risk, as per best practice guidelines.

How to Approach the Question

This is a clinical process question asking for the 'most appropriate' nursing action.
Read the stem carefully to identify the core task: administering a blood transfusion.
Evaluate each option against the established safety principles (the 'rights') of this procedure.
Option A: Recall fluid compatibility. Dextrose is incompatible with blood and causes hemolysis.
Option B: Recall initial monitoring protocols. The rate must be slow at first to watch for reactions, not fast.
Option D: Recall the maximum time limit for infusion. The limit is 4 hours to prevent bacterial growth.

Concept Tested & Keywords

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E6 Nursing Fundamentals Taylor pp. 830-832, 831-833

Practise the full BTSC Staff Nurse 1 August-2025

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