After just starting a blood transfusion, the patient experiences an anaphylactic reaction. What is the priority nursing action in this situation?

1. A

   Stop blood transfusion and continue IV patency with normal saline

2. B

   Inform to doctor

3. C

   Slow the infusion

4. D

   Administer hydrocortisone

Appeared in: AIIMS Delhi NO - 2018

Explanation

• The priority nursing action during an anaphylactic transfusion reaction is to immediately stop the infusion. This is the single most important step to prevent the patient from receiving more of the blood product causing the life-threatening allergic response.
• After stopping the blood, the IV line must be kept open with a new infusion of normal saline using new tubing. This ensures that no more blood from the tubing enters the patient and provides a patent route for administering emergency medications.
• This combined action addresses the immediate cause of the problem (stopping the allergen) and prepares for the necessary treatment (maintaining IV access).

Why Other Options Were Wrong

• Option B: Informing the doctor is a critical step, but it is not the first priority. The nurse must first take the immediate, independent action of stopping the transfusion to ensure patient safety. Delaying this to find a doctor would cause harm.
• Option C: Slowing the infusion is dangerous as it continues to expose the patient to the allergen, which will worsen the anaphylactic reaction. For a severe reaction, the transfusion must be stopped completely, not just slowed.
• Option D: Administering hydrocortisone is a medical treatment for the reaction, not the priority nursing action. It is a dependent intervention that requires a physician's order and is given only after the transfusion has been stopped.

Related Visual

Clinical Relevance

• Nursing practice connection: Safe nursing care depends on performing Priority nursing action for anaphylactic blood transfusion reaction in the correct sequence, documenting the action clearly, and monitoring for the expected response.
• In any suspected transfusion reaction, the nurse's first action is always to stop the infusion to protect the patient from further harm. This is a critical patient safety principle.
• Nurses must stay with the patient during the first 15 minutes of a transfusion, as this is when most severe reactions, like anaphylaxis, occur.
• Anaphylaxis is a life-threatening emergency. The nurse must be prepared to initiate basic life support and call for the emergency response team while performing the initial steps.

How to Approach the Question

• First, identify the type of question. This is a priority-setting question in a clinical emergency scenario.
• Recognize the life-threatening condition presented: 'anaphylactic reaction.' This signals the need for immediate, decisive action.
• Apply the nursing process and safety principles. The first step is always to assess and intervene to remove the cause of harm.
• Evaluate the options based on what is the most immediate and impactful action the nurse can take independently to stabilize the patient.
• Option A (Stop transfusion) directly removes the offending agent. Options B, C, and D are subsequent or incorrect actions.
• Therefore, stopping the transfusion and maintaining IV access is the highest priority to ensure patient safety and prepare for further treatment.

Concept Tested & Keywords

• Concept Tested: Priority nursing action for anaphylactic blood transfusion reaction
• Stem keywords: blood transfusion, anaphylactic reaction, priority nursing action
• Lead-in keywords: priority
• Clinical cues: The reaction occurred 'just after starting' the transfusion, which is characteristic of a severe, acute reaction like anaphylaxis.

Question ID

QZn8ivPFVPGzChJpQ94wAq

Copy ID

Reference Book

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