The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness
What is the most appropriate initial action for the nurse to take?
A) Notify the patient's physician.
B) Stop the transfusion immediately.
C) Remove the patient's IV access.
D) Assess the patient's chest sounds and vital signs.
Ans: B
Feedback:
Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the patient's vital signs, and notify the physician. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The patient's IV access should not be removed.
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