The nurse is caring for a client receiving a blood transfusion. 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. Based on this data, which is the priority intervention for this client?
A) Decrease the rate of the transfusion.
B) Notify the client's health care provider.
C) Prepare to resuscitate the client.
D) Discontinue the transfusion.
Answer: D
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 health care provider to collaborate on further treatment, but this action should be after the transfusion is discontinued. Slowing the rate of the transfusion allows additional blood to be infused. At this point, there is no need to prepare for resuscitation.
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