A nurse is preparing to administer a blood transfusion to a client. Which of the following actions should the nurse take?
Explanation & Rationale
Rationale: A. Attach a single-line administration set: A blood transfusion requires a Y-type tubing with a filter and two lines—one for the blood and one for normal saline—to allow flushing and compatibility. A single-line set is inadequate. B. Prime the tubing with 0.9% sodium chloride: Only 0.9% sodium chloride (normal saline) should be used to prime blood tubing, as it is compatible with blood products and prevents clotting or hemolysis. Dextrose or other solutions can cause cell lysis. C. Use an IV catheter that is at least 24-gauge: A 24-gauge catheter is too small for routine blood transfusions. A larger bore, such as 18- to 20-gauge, is recommended to reduce the risk of hemolysis and allow adequate flow. D. Use tubing that does not have a filter in the drip chamber: Blood transfusion sets must include a filter (usually 170–260 microns) to trap clots and debris. Using tubing without a filter increases the risk of transfusion reactions.