A client receiving a blood transfusion for 15 minutes complains of suddenly feeling cold and is shivering. Blood pressure has decreased since the last assessment. Which is the nurse's priority action?
1. Notify the health care provider.
2. Monitor the client's blood pressure every 5 minutes.
3. Stop the blood infusion, and run the normal saline on the other side of the Y tubing.
4. Stop the blood infusion, and remove the tubing from the IV catheter, replacing it with normal saline.
4
Rationale 1: Only after the blood infusion is discontinued would the nurse notify the health care provider.
Rationale 2: Only after the blood infusion is discontinued would the nurse monitor the client's condition.
Rationale 3: Stopping the blood infusion and running saline through the blood tubing will administer the blood found in the tubing, and could make the transfusion reaction worse.
Rationale 4: The nurse should completely discontinue the blood infusion, disconnecting the tubing from the IV catheter and placing normal saline or the ordered solution infusing prior to beginning the blood infusion with new tubing.
Global Rationale: The nurse should completely discontinue the blood infusion, disconnecting the tubing from the IV catheter and placing normal saline or the ordered solution infusing prior to beginning the blood infusion with new tubing. Stopping the blood infusion and running saline through the blood tubing will administer the blood found in the tubing, and could make the transfusion reaction worse. Only after the blood infusion is discontinued would the nurse notify the health care provider and monitor the client's condition.
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