A patient is receiving a transfusion of packed red blood cells. Ten minutes after the infusion begins, the patient reports low back pain and a headache. Which of these actions should the nurse take first?
a. Start the new 0.9% normal saline infusion.
b. Prepare a new 0.9% normal saline infusion.
c. Stop the blood infusion.
d. Notify the physician STAT.
ANS: C
Low back pain and headache can be symptoms of a transfusion reaction. If symptoms of a reaction are noted, the blood is immediately stopped so that no more blood is infused into the patient. A new normal saline infusion with new tubing is prepared and started to keep the vein patent should medications need to be administered as ordered. New tubing must be used so that not one more drop of blood enters the patient.
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