A patient receiving a blood transfusion begins to complain of chills, itching, and shortness of breath. What is the nurse's immediate priority action?

Appeared in: HSSC Staff Nurse - 2015

Explanation

The patient's symptoms (chills, itching, shortness of breath) are classic signs of an acute transfusion reaction.
The immediate and most critical nursing action is to stop the transfusion. This prevents the patient from receiving more of the blood product, which is causing the adverse reaction.
Delaying this action can lead to more severe complications, including anaphylactic shock, acute intravascular hemolysis, or even death.
All other actions, while important, are secondary to stopping the infusion of the causative agent.

Option A: Slowing the infusion rate is insufficient and dangerous. It allows the harmful blood product to continue entering the patient's circulation, which can worsen the reaction.
Option C: Administering an antihistamine is a subsequent step, not the first priority. It treats the symptoms but does not address the root cause. The transfusion must be stopped first.
Option D: While checking vital signs is crucial, it is not the first action. The priority is to eliminate the cause of the problem. Continuing to monitor without stopping the transfusion would be negligent.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Management of Blood Transfusion Reactions in the correct sequence, documenting the action clearly, and monitoring for the expected response.
Recognizing and acting immediately on signs of a transfusion reaction is a critical patient safety responsibility for nurses. Failure to stop the transfusion promptly can have life-threatening consequences.
This scenario underscores the importance of the nursing process: assessment (recognizing the signs), diagnosis (suspecting a reaction), planning/implementation (stopping the transfusion), and evaluation (monitoring the patient's response).
What if the patient only reported feeling itchy with a small rash, but had no chills or shortness of breath? The priority action remains the same: stop the transfusion. Even mild symptoms can escalate quickly, and the initial intervention is always to stop the infusion and assess.

How to Approach the Question

First, identify the keywords in the question: 'immediate priority action'. This tells you to look for the single most important thing to do first.
Next, analyze the clinical scenario. The patient is receiving a blood transfusion and develops chills, itching, and shortness of breath. Recognize these as hallmark signs of a transfusion reaction.
Apply the fundamental safety principle for infusions: if an adverse reaction is suspected, the first step is always to stop the infusion to prevent further harm.
Evaluate the options based on this principle. 'Stop the transfusion immediately' directly addresses the cause and prevents worsening of the condition. The other options are subsequent or incorrect actions.

Concept Tested & Keywords

Concept Tested: Management of Blood Transfusion Reactions
Stem keywords: blood transfusion, chills, itching, shortness of breath
Lead-in keywords: immediate priority action
Clinical cues: The combination of chills, itching, and shortness of breath strongly suggests an acute transfusion reaction, which requires immediate intervention.

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

E6 Nursing Fundamentals Taylor p. 830-832

Practise the full HSSC Staff Nurse - 2015

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