The provider prescribes one unit of packed red blood cells to be administered to a client. To ensure the client's safety, which action will the nurse take during administration of blood products?

• A. Stay with client during first 15 minutes of infusion.
• B. Flush packed red blood cells with 5% dextrose and 0.45% normal saline.
• C. Remove the intravenous catheter if a blood transfusion reaction occurs.
• D. Administer the red blood cells through a percutaneously inserted central catheter line with a 20-gauge needle.

Answer: (A)

The important safety step is to monitor the patient during the first moments of a blood product infusion because most acute transfusion reactions happen early. By staying with the client for the initial 15 minutes, the nurse can promptly notice signs such as fever, chills, itching or hives, shortness of breath, back or chest pain, flushing, or a drop in blood pressure, and intervene immediately if a reaction begins. If any reaction is suspected, the infusion is stopped right away, the IV line is kept open with normal saline, and the provider is notified for further instructions.

Why the other options aren’t the best safety action: flushing with a dextrose-containing solution is avoided because it can cause hemolysis or incompatibility with the transfused cells; removing the IV catheter during a suspected reaction would delay treatment and is unsafe; and using a central venous catheter with a 20-gauge needle isn’t a requirement for safety during a routine transfusion and isn’t the action that prevents early reaction-related risks alone—monitoring during the first part of the infusion is the critical step.