The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. What should be the nurse's initial action?
a. Cover with a warm blanket
b. Take the patient's temperature
c. Elevate the head of the bed
d. Stop the transfusion and continue with saline
ANS: D
Mild transfusion reaction signs and symptoms include dermatitis, diarrhea, fever, chills, urticaria, and cough The initial intervention should be to stop the transfusion and continue with saline. Elevation of the head, taking vital signs, and covering with a warm blanket are not wrong, but are not of primary importance at this time.
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