The nurse assesses a client 5 minutes after initiating a blood transfusion. The client has shortness of breath, itching, and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next?

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Signs of a transfusion reaction include chills, fever, low back pain, flushing, and itching. Nursing interventions include: Stop transfusion immediately and disconnect tubing at the catheter hub.Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse (Option B).Notify health care provider (HCP) and blood bank.Monitor vital signs.Recheck labels, numbers, and the client's blood type.Treat client's symptoms according to the HCP's prescription.Collect blood and urine specimens to evaluate for hemolysis.Return blood and tubing set to the blood bank for additional testing.Complete necessary facility paperwork to document the reaction. Stop transfusion immediately and disconnect tubing at the catheter hub. Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse (Option B). Notify health care provider (HCP) and blood bank. Monitor vital signs. Recheck labels, numbers, and the client's blood type. Treat client's symptoms according to the HCP's prescription. Collect blood and urine specimens to evaluate for hemolysis. Return blood and tubing set to the blood bank for additional testing. Complete necessary facility paperwork to document the reaction. (Option A) Monitoring vital signs would be the step after ensuring IV access, administering normal saline, and notifying the HCP. (Option C) The nurse should ensure continued IV access before notifying the HCP. The HCP will likely prescribe IV medications (eg, vasopressors, antihistamines, corticosteroids) to treat the transfusion reaction, so a patent IV is critical. (Option D) Mislabeling blood and administering the wrong blood type are the most common causes of a transfusion reaction. However, maintaining IV access takes priority over investigating a potential clinical error. Educational objective: During a blood transfusion reaction, the nurse should immediately stop the transfusion and initiate normal saline to maintain IV access and prevent hypotension and vascular collapse.

The Nurse Assesses a Client 5 Minutes After Initiating a Blood