The nurse is caring for a client receiving a transfusion of packed red blood cells who develops chills, fever, headache, and anxiety 30 minutes after the transfusion is started. After stopping the transfusion, which of the following actions is priority?
A)Draw blood for a new crossmatch
B)Send a urine specimen to the laboratory
C)Give the PRN diphenhydramine
D)Administer the PRN acetaminophen

Question

Quizplus · Accepted Answer

The client's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected.
Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

The Nurse Is Caring for a Client Receiving a Transfusion