Fifteen minutes after a transfusion of packed red blood cells is started, a client has symptoms of back pain and dyspnea and a pulse rate of 124 beats/minute. Which of the following actions should the nurse implement initially?
A)Administer oxygen therapy at a high flow rate.
B)Obtain a urine specimen to send to the laboratory.
C)Notify the health care provider about the symptoms.
D)Disconnect the transfusion and infuse normal saline.

Question

Quizplus · Accepted Answer

The client's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

Fifteen Minutes After a Transfusion of Packed Red Blood Cells