A patient receiving blood begins complaining of severe chest pain and a feeling of warmth. What should the nurse do first?
a. Call the physician.
b. Administer diuretics as ordered.
c. Discontinue the blood transfusion.
d. Assess vital signs and cardiovascular status.
ANS: C
The nurse will likely carry out all the actions, but the blood must be discontinued first, to stop the source of the reaction. A. The physician can be notified after the blood is stopped. D. The nurse will continue to measure vital signs and cardiovascular status after the infusion is stopped. B. The nurse will provide medication therapy as prescribed but only after the infusion has been stopped.
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