A client is receiving blood transfusion, after 20 minutes patient showing transfusion reaction, what is the priority nursing intervention of the assigned nurse?

1. A

   Stop the transfusion immediately

2. B

   Call to the doctor

3. C

   Monitor vital signs

4. D

   Slow the rate of transfusion

Appeared in: AIIMS Rishikesh & Jodhpur NO - 2017

Explanation

• The absolute first priority when a transfusion reaction is suspected is to immediately stop the infusion.
• This action prevents the patient from receiving more of the blood product that is causing the adverse reaction, which is critical to minimizing the severity of the event.
• All other interventions, such as notifying the provider or monitoring vitals, are necessary but are secondary to stopping the transfusion to ensure immediate patient safety.

Why Other Options Were Wrong

• Option B: While notifying the doctor is essential, it is not the first action. The nurse must first intervene to protect the patient from further harm by stopping the transfusion.
• Option C: Monitoring vital signs is a crucial part of assessment but not the priority intervention. The primary goal is to remove the cause of the reaction first.
• Option D: Slowing the rate is a dangerous action as it continues to expose the patient to the blood product causing the reaction, potentially worsening their condition.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Priority nursing intervention for a suspected blood transfusion reaction in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• Recognizing and acting immediately on a transfusion reaction is a critical, life-saving nursing responsibility. The sequence of actions is standardized to ensure patient safety.
• In India, the National Blood Transfusion Council guidelines also emphasize stopping the transfusion immediately as the first step in managing an adverse reaction.
• What if? If the patient only reported mild itching with no other symptoms, the nurse must still stop the transfusion immediately. A mild symptom can be the first sign of a severe, life-threatening anaphylactic or hemolytic reaction.

How to Approach the Question

• Identify the keyword 'priority' in the question. This indicates you must select the most important and immediate action.
• Analyze the clinical situation: a patient is showing signs of a transfusion reaction.
• Recall the fundamental principle of patient safety: first, remove the source of harm.
• Evaluate the options. 'Stop the transfusion immediately' is the only option that directly addresses and removes the cause of the problem.
• The other options, 'Call to the doctor' and 'Monitor vital signs', are subsequent actions. 'Slow the rate' is an incorrect and harmful action.

Concept Tested & Keywords

• Concept Tested: Priority nursing intervention for a suspected blood transfusion reaction.
• Stem keywords: blood transfusion, transfusion reaction, priority nursing intervention
• Lead-in keywords: priority
• Clinical cues: A patient developing symptoms 20 minutes into a blood transfusion is a classic sign of an acute transfusion reaction.

Question ID

QEv33y461fkNsCPReg9v1p

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 5 pp. 76-78, 77-79

E6 Nursing Fundamentals Taylor p. 830-832