Anurse is administering packed rbcs to a client. the client reports chills, lower back pain, and nausea 10 min after the infusion begins which of
the following actions should the nurse take first?

Which is the priority nursing action?

1. Administering antihistamines STAT for an allergic reaction.

2. Notifying the physician of a possible transfusion reaction.

3. Obtaining a urine and serum specimen to send to the lab immediately.

4. Stopping the transfusion and maintaining a patent IV catheter."

The answer is "Stopping the transfusion and maintaining a patent IV catheter."

Explanation:

Blood transfusion refers to the process of transferring donated blood to another person for some reasons. This can be done through a narrow tube which serves as the passage for blood to travel. Common reasons for blood transfusion are: liver disease, dengue hemorrhagic fever, surgery, anemia, kidney disease, and so on.

Packed RBCs refers to the red blood cells that are meant for blood transfusion. It is common for people who have lost a great amount of blood.

In the situation above, the nurse administered the packed RBCs to a client, then the client reports his symptoms. Chills, lower back pain and nausea are symptoms of transfusion reaction. This can range from non-severe to life-threatening condition. This means that the body thinks that the donor blood is a foreign object, thus the antibodies attack on it, which causes the symptoms. It could be that the blood wasn't meant for the patient.

Thus, it is very important to stop the transfusion immediately. It is also important to replace the blood with a normal saline solution, thus you have to maintain a patent IV catheter (this is where the solution passes through).

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