The nurse is providing care to a patient 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?

Question

Quizplus · Accepted Answer

The symptoms described are indicative of a possible transfusion reaction, which is a medical emergency. The nurse's actions should include: A) monitoring the patient's vital signs frequently to assess for changes or deterioration, B) stopping the blood transfusion immediately to prevent further harm and notifying the physician for further instructions, C) sending the tubing and unused blood to the blood bank for investigation to determine the cause of the reaction, and D) obtaining a urine sample for analysis to check for signs of hemolysis or other abnormalities related to the transfusion reaction. Discontinuing the IV site (E) is not immediately necessary and could remove venous access needed for emergency interventions.

The Nurse Is Providing Care to a Patient Who Is