Difficulty: Medium
Average Score: 71%
Simulated
A client began receiving an intravenous (IV) infusion of packed red blood cells 30 minutes ago. What is the initial nursing action when the client reports itching and a tight sensation in the chest?
Correct answer
A
Rationale
The symptoms reported by the client indicate that the client is experiencing a transfusion reaction. The first action of the nurse when a transfusion reaction is observed is to discontinue the transfusion. The IV of normal saline with new IV tubing is started and the primary health care provider is notified. The nurse then checks the client's vital signs: temperature, pulse, and respirations and then rechecks the unit of blood as appropriate for infusion into the client.