The nurse is administering 1 unit of packed red blood cells as ordered by the primary care provider. While the nurse is measuring vital signs 15 minutes after starting the transfusion, the patient complains of chills and back pain
What is the nurse's first action?
a. Stop the blood transfusion and keep the vein patent by administering saline to infuse from the other side of the Y tubing.
b. Slow the blood transfusion and notify the charge nurse.
c. Disconnect the blood tubing from the catheter and replace it with an infusion of normal saline.
d. Stop the blood transfusion and notify the primary care provider.
C
The nurse's first priority is to stop the blood transfusion. To keep the intravenous site patent, normal saline can be infused at a keep-open rate, but the tubing must be changed to avoid administering more blood as the saline flushes the blood from the tubing. If the tubing is not changed, additional blood will be administered, and the possible transfusion reaction will increase. The charge nurse or the primary care provider should be notified only after the patient has been assessed.
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