A patient's vital signs prior to a blood transfusion were:

Question

T = 97.6°F (36.4°C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the patient began complaining of feeling "itchy and hot." The nurse discovered a rash on the patient's trunk. Vital signs were T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention?
a. Administer an antihistamine (antiallergenic) medication.
b. Flush the blood tubing with D5W immediately.
c. Prepare for emergency resuscitation.
d. Stop the blood transfusion immediately.

Answer 1

D
The nurse should suspect a transfusion reaction. When a transfusion reaction is suspected, the infusion should be stopped immediately. The blood bag and tubing must be sent to the laboratory for analysis. A new IV line of normal saline should be hung. Diphenhydramine (an antihistamine) may be ordered once the physician has been notified of the patient's condition. There is no information indicating that the patient is in danger of cardiovascular collapse or requires resuscitation.