A patient is undergoing blood transfusion and suddenly shows complaints of transfusion reaction. What will be the priority nursing intervention?

Appeared in: AIIMS Delhi NO- 2019

Explanation

The most critical first step in managing a suspected transfusion reaction is to immediately stop the infusion. This action prevents the patient from receiving more of the blood product that is causing the adverse reaction.
The next priority is to maintain the patency of the intravenous (IV) line. This is done by disconnecting the blood tubing and connecting a new administration set with 0.9% normal saline.
Keeping the IV line open is crucial as it provides an essential route for administering emergency medications (such as antihistamines, corticosteroids, or epinephrine) and IV fluids to manage symptoms like hypotension or shock.

Option A: Removing the cannula is incorrect because it eliminates the intravenous access needed to administer emergency medications and fluids to treat the reaction.
Option C: Continuing the transfusion is extremely dangerous and would worsen the patient's reaction, potentially leading to life-threatening complications like shock, renal failure, or respiratory distress.
Option D: Continuing the transfusion is contraindicated. While the bag will eventually be discarded or returned to the lab, the immediate priority is patient safety, which requires stopping the infusion.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Priority Nursing Interventions for Blood Transfusion Reactions in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Transfusion reactions are medical emergencies. Rapid recognition and immediate, correct intervention by the nurse are critical to prevent severe morbidity or mortality.
Nurses must be vigilant in monitoring patients during transfusions, especially within the first 15 minutes when most severe reactions occur, for signs like fever, chills, itching, dyspnea, or back pain.
The blood bag, tubing, and patient's blood/urine samples are crucial evidence for the blood bank to investigate the cause of the reaction, preventing future incidents.

How to Approach the Question

Identify the question type: This is a priority-based clinical scenario question, asking for the most important immediate action.
Analyze the scenario: A patient is actively having a transfusion reaction. This is an emergency.
Apply the 'first, do no further harm' principle. The transfusion is the source of the problem, so it must be stopped. This immediately eliminates options suggesting to 'Complete the transfusion'.
Evaluate the remaining options based on the next critical need. The patient will require treatment for the reaction, which necessitates a patent IV line.
Compare 'remove cannula' vs. 'flush with NS'. Removing the cannula eliminates the vital IV access. Flushing with NS (after disconnecting the blood) maintains this access.
Conclude that stopping the infusion and maintaining the line with NS is the highest priority to ensure patient safety and enable further treatment.

Concept Tested & Keywords

Concept Tested: Priority Nursing Interventions for Blood Transfusion Reactions
Stem keywords: blood transfusion, transfusion reaction, priority nursing intervention
Lead-in keywords: priority
Clinical cues: sudden complaints of transfusion reaction
Negative lead-in flag: false

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Harrison's Principles of Internal Medicine, 21st Edition p. 830-832

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