The nurse admitted a patient with low Hemoglobin of 7.3g/dL,and Hematocrit of 24.4%.The doctor orders to transfuse PRBC of 1unit .And to check H/H one hour after transfusion.Five to ten minutes into the transfusion, patient started itching all over,complaining of chill and hives.
The first and immediate reaction of the Registered Nurse will be?.
(A )Tell the patient that this is normal, and will stop at the end of the transfusion.
(B )Call the charge nurse to assist.
(C)Complain about the unfair assignment.
(D) Stop the blood transfusion immediately and notify the doctor.
Correct answer D.
Rationale: A is wrong, patient is having a blood transfusion reaction, stop the transfusion. Patient is not tolerating it well.
B is wrong you don’t need the charge nurse finger to push the pump to stop the transfusion. So calling the charge nurse will be for advice on what to do .C is also wrong,complain of unfair assignment. Really when your patient is having a transfusion reaction?. You can complain later but do no harm to your patient. The best answer is D.And that is to stop blood infusion and notify the doctor.