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 priority action is to first stop the transfusion to prevent any further administration of the blood product causing the adverse reaction.
The second crucial step is to maintain the patency of the intravenous (IV) line by disconnecting the blood tubing and infusing 0.9% normal saline through new tubing.
This ensures a stable IV access point is available for administering emergency medications (like antihistamines or steroids) and fluids to manage the reaction.
This combination of actions addresses the immediate threat while preparing for subsequent life-saving interventions.

Option A: Stopping the infusion is correct, but removing the cannula is a critical error. The IV access is essential for administering emergency medications and fluids to treat the reaction.
Option C: Continuing the transfusion is extremely dangerous and can lead to severe complications, including shock, renal failure, and death. Administering medication without stopping the transfusion is incorrect.
Option D: Continuing the transfusion is contraindicated. Discarding the bag immediately would prevent the blood bank from analyzing it to determine the cause of the reaction.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Priority nursing interventions for a blood transfusion reaction in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Recognizing and responding to a transfusion reaction is a critical patient safety responsibility for nurses. A delayed response can have life-threatening consequences.
The immediate priority is always to stop the source of harm (the blood product) and then to stabilize the patient by maintaining IV access for treatment.
In Indian healthcare settings, strict adherence to transfusion protocols, including the two-person verification process and vigilant patient monitoring, is essential to prevent and manage adverse events.

How to Approach the Question

First, identify the question type: This is a clinical scenario asking for the priority nursing action.
Analyze the situation: A patient is actively receiving a blood transfusion and develops a complication.
Recall the principles of priority setting in nursing: The first step is often to stop the process that is causing harm.
Evaluate the options based on this principle. Options C and D suggest continuing the transfusion, which would increase the harm. Eliminate them immediately.
Compare the remaining options, A and B. Both correctly state to stop the infusion. The key difference is the action regarding the IV line.
Think about the next steps. A transfusion reaction is an emergency that may require IV medications. Therefore, removing the IV access (Option A) is incorrect and potentially dangerous. Maintaining IV access with a safe fluid like normal saline (Option B) is the logical and correct next step.

Concept Tested & Keywords

Concept Tested: Priority nursing interventions for a blood transfusion reaction.
Stem keywords: blood transfusion, transfusion reaction, priority nursing intervention
Lead-in keywords: priority
Clinical cues: sudden complaints of transfusion reaction

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

E6 Nursing Fundamentals Taylor p. 830-832

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