A patient receiving a unit of packed red blood cells as treatment for anemia begins to vomit and experience extreme gastrointestinal cramping. What should the nurse do? (Select all that apply.)
a. Stop the transfusion.
b. Administer intravenous (IV) heparin.
c. Prepare to provide cardiopulmonary resuscitation (CPR) if necessary.
d. Stay with the patient and call for help.
e. Flush the blood tubing with normal saline.
ANS: A, C, D
Anaphylactic reactions are not common but may be seen more often in patients who have received many transfusions. In this type of reaction, the very first milliliters of blood containing the allergens to pass into the patient's system may be enough to cause the patient to develop respiratory or cardiovascular collapse. Other more common symptoms include severe gastrointestinal cramping and instant vomiting. The nurse should stop the transfusion at once and stay with the patient. Have someone else notify the RN and the HCP. Provide CPR if necessary. B. IV heparin is not used to treat this blood reaction. E. Flushing the blood tubing with normal saline will not help reduce the effects of this transfusion reaction.
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