Ten minutes into a packed red blood cell transfusion, a patient develops acute fever, chills, dyspnea, flank pain, and dark urine. What is the immediate priority nursing action?
Answer and explanation
Correct answer: A. Stop the transfusion immediately and maintain IV access with normal saline
- Step 1: Fever, flank pain, and hemoglobinuria during transfusion indicate an acute hemolytic transfusion reaction (often due to ABO incompatibility).
- Step 2: The immediate priority intervention is to stop the transfusion immediately, disconnect the blood tubing from the venous cannula, and infuse 0.9% normal saline through new tubing to maintain vascular patency while notifying the physician and blood bank.
Answer
Stop the transfusion immediately and maintain IV access with normal saline.
Why not the others: Continuing or slowing the transfusion infuses more incompatible cells, worsening intravascular hemolysis and acute tubular necrosis; D5W can cause hemolysis of RBCs remaining in line.
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