Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority?
1. Notify the client's physician.
2. Discontinue the transfusion.
3. Slow the rate of the transfusion.
4. Prepare to resuscitate the client.
Correct Answer: 2
Rationale 1: This would not be the nurse's first action.
Rationale 2: The priority intervention is to discontinue the transfusion. If this client is having a transfusion reaction, it will be better to limit the amount of blood transfused. The nurse would also contact the physician to collaborate on further treatment, but this action should be after the transfusion is discontinued.
Rationale 3: Slowing the rate of the transfusion allows additional blood to be infused.
Rationale 4: At this point, there is no need to prepare for resuscitation.
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