The nurse is caring for a patient who is receiving a blood transfusion. One hour into the transfusion, the patient's blood pressure decreases significantly and the patient complains of a severe headache. What is the priority action of the nurse?
a. Check the patient's temperature and administer acetaminophen (Tylenol) if higher than 101 ° F.
b. Recheck the patient's blood pressure in 15 minutes after administering pain medication.
c. Stop the blood transfusion and administer 0.9% normal saline through new IV tubing.
d. Double-check that the transfusion blood type is an exact match to the patient.
ANS: C
A significant drop in blood pressure and a severe headache are signs that the patient may be experiencing a transfusion reaction. The transfusion should be stopped and 0.9% normal saline should be administered through new IV tubing to prevent infusion of additional blood through the tubing used for the transfusion. The physician should be notified immediately to evaluate the patient. Ensuring that the transfusion blood type is an exact match to the patient is done before the transfusion is begun.
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