A nurse is caring for a patient who develops a suspected acute hemolytic transfusion reaction 10 minutes after starting a unit of packed red blood cells. What is the very first action the nurse must take?

Answer and explanation

Correct answer: A. Stop the transfusion immediately and maintain IV access with normal saline using new tubing

  1. Step 1: At the earliest indication of any acute transfusion reaction (fever, chills, back pain, dyspnea, hypotension), the nurse must immediately stop the transfusion.
  2. Step 2: The blood administration tubing must be disconnected from the IV cannula, and the IV line kept patent with 0.9% Normal Saline using fresh IV tubing to prevent administering residual blood in the line.
Answer
Stop the transfusion immediately and maintain IV access with normal saline using new tubing.
Why not the others: 'Slow the infusion rate' allows continued entry of incompatible RBCs, escalating lethal complement-mediated intravascular hemolysis and renal failure; 'Administer antipyretic and observe' masks symptoms of fatal ABO incompatibility; 'Chest radiograph' delays essential acute emergency interventions.

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