A nurse is caring for a patient receiving a transfusion and assesses that the patient is wheezing and is complaining of back pain. What nursing action should take place after stopping the trans-fusion?
a. Discontinue the intravenous (IV) transfu-sion.
b. Notify the charge nurse.
c. Administer heparin.
d. Raise the patient's head.
B
The charge nurse should be notified immediately after the transfusion is stopped. The charge nurse will notify the physician and the laboratory or blood bank. The head of the bed should be raised to aid in respiration, and oxygen should be administered in high doses. The blood tubing and bag should not be discarded because the blood bank will want it to check the accuracy of the typing.
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