The nurse is caring for a patient who is receiving a blood transfusion. Fifteen minutes into the transfusion, the patient's blood pressure decreases significantly, and the patient complains of a severe headache. What is the priority action of the nurse?

Question

Quizplus · Accepted Answer

A significant drop in blood pressure and a severe headache are signs that the patient may be experiencing a transfusion reaction. Also, most reactions to a transfusion occur within the first 15 minutes of initiation. Therefore the nurse should remain with the patient at the bedside during this time to observe for signs of a reaction. The transfusion should be stopped and 0.9% normal saline should be administered through new IV tubing to prevent infusion of additional blood through the tubing used for the transfusion. The physician should be notified immediately to evaluate the patient. Ensuring that the transfusion blood type is an exact match to the patient is done before the transfusion is begun.

The Nurse Is Caring for a Patient Who Is Receiving