The nurse is providing care to a client who is receiving a blood transfusion and who becomes acutely short of breath and anxious within a few minutes of the nurse's initiating the transfusion.Which of the following actions will be included in the nurse's care? Select all that apply.

Question

Quizplus · Accepted Answer

The nurse should immediately stop the blood transfusion and notify the physician as a first step in response to signs of a possible transfusion reaction, such as acute shortness of breath and anxiety. Frequent checks of the vital signs are necessary to monitor the patient's condition closely. Sending the tubing and unused blood to the blood bank is important for investigation of the reaction. Obtaining a urine sample for analysis can help in identifying hemolysis if that is the cause of the reaction. Discontinuing the IV site is not recommended as the site may be needed for administration of medications or fluids to treat the reaction.

The Nurse Is Providing Care to a Client Who Is