Ten minutes after a blood transfusion begins, a patient reports chills and back pain, and the temperature rises. What is the priority nursing action?
Correct answer: A. Stop the transfusion and keep the IV line open with normal saline
- A. Stop the transfusion and keep the IV line open with normal saline
- B. Reduce the rate and continue while observing the patient
- C. Give an antipyretic and restart the same unit
- D. Flush the blood rapidly through the existing tubing
Explanation
Chills, fever and back pain may indicate an acute haemolytic transfusion reaction, which is life threatening. Stop the transfusion immediately, keep the vein open with new tubing and normal saline, recheck identity, notify the clinician and follow the reaction protocol.
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About IV Fluids and Blood Transfusion
IV therapy covers crystalloid and colloid fluids, electrolyte replacement, maintenance and resuscitation fluids, infusion equipment and complications such as infiltration, phlebitis, fluid overload and electrolyte imbalance. Blood transfusion content includes compatibility, cross matching, administration precautions and recognition of haemolytic, febrile and allergic reactions, distinct from ordinary IV fluid reactions.
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