Difficulty: Medium
Average Score: 87%
Simulated
The nurse is caring for a client receiving a unit of packed red blood cells (PRBCs). The client reports chills, and their oral temperature is 103┬░ F (39.4┬░ C). Which action should the nurse take first?
Correct answer
C
Rationale
Chills and a fever of 103┬░F during a PRBC transfusion suggest a possible febrile or hemolytic reaction. The first action is to pause the transfusion to prevent further administration of potentially problematic blood. Assessing vital signs, obtaining cultures, and notifying the provider follow after stopping the transfusion.