One hour after starting a unit of packed red blood cells, a nurse observes that a patient receiving the transfusion is reporting flank pain and has a temperature of 101.8$\degree$F (38.8$\degree$C).The nurse's first action should be to:
A)Assess the patient for signs of rash, hives, or angioedema.
B)Confirm that the name on the label on the blood transfusion matches the patient's armband.
C)Medicate the patient with acetaminophen that is ordered prn for pain or fever.
D)Stop the transfusion and maintain IV access with normal saline.

Question

Quizplus · Accepted Answer

The patient is exhibiting signs of a transfusion reaction, which can be life-threatening. The first action should be to stop the transfusion immediately to prevent further harm. Maintaining IV access with normal saline will ensure the patient remains hydrated while the healthcare team assesses the situation further. Once the patient is stable, further investigation can be pursued to determine the cause of the reaction.

One Hour After Starting a Unit of Packed Red Blood °\degree°

One Hour After Starting a Unit of Packed Red Blood $\degree$