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

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 is critical because it prevents the patient from receiving more of the blood product that is causing the adverse reaction, which minimizes the potential for severe complications or death.
All other interventions, such as notifying the provider and monitoring vital signs, are necessary but are performed only after the transfusion has been stopped to ensure patient safety.

Option B: This is a critical step, but it is not the first priority. The nurse must first take immediate action to protect the patient from further harm before notifying the provider.
Option C: Monitoring vital signs is an essential assessment but not the priority intervention. The primary goal is to stop the cause of the reaction, not just observe its effects.
Option D: This action is dangerous as it continues to administer the blood product causing the reaction, potentially worsening the patient's condition.

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 suspected transfusion reaction is a critical, life-saving nursing skill. The nurse is the first line of defense in preventing severe harm.
Patient safety protocols mandate that stopping the transfusion is an independent nursing action that does not require a physician's order.
What if? If the patient reports only 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 anaphylactic or hemolytic reaction, and early intervention is key.

How to Approach the Question

First, identify the keywords in the question. The most important word here is 'priority'. This indicates you must choose the most critical, immediate action.
Analyze the clinical situation: a patient is actively receiving a blood transfusion and is showing signs of a reaction. The core problem is the transfusion itself.
Apply the nursing principle of patient safety: the first step is always to remove the source of harm. In this case, the blood is the source of harm.
Evaluate each option based on this principle. 'Stop the transfusion immediately' is the only option that directly removes the cause of the problem.
Recognize that other options like 'Call to the doctor' and 'Monitor vital signs' are correct actions but are secondary to stopping the infusion. 'Slow the rate' is an incorrect and unsafe 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 showing signs of a transfusion reaction 20 minutes after initiation.

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E6 Medicine Davidson Principles Practice 24e p. 830-832

Practise the full AIIMS Rishikesh & Jodhpur NO - 2017

Attempt every question from this paper in a timed mock, then review the full solution for each one.