During a blood transfusion, a patient complains of chills, low back pain, and fever. The nurse's first action… - NORCET 9 Mains - 2025

NORCET 9 Mains - 2025

Medical & Surgical Nursing

Hard

Appeared in: NORCET 9 Mains - 2025

Explanation

The patient's symptoms (chills, low back pain, fever) are hallmark signs of an acute hemolytic transfusion reaction, a life-threatening emergency.
The immediate priority is to stop the transfusion to prevent further administration of incompatible blood, which is causing the hemolysis (destruction of red blood cells).
Keeping the IV line open with a new set and normal saline is the essential next step to maintain venous access for emergency drugs and fluids to manage complications like hypotension and renal failure.

Option A: Slowing the infusion is insufficient and dangerous. It allows more incompatible blood to enter the patient's system, which will worsen the life-threatening hemolytic reaction.
Option C: Antihistamines are used to treat allergic reactions (Type I hypersensitivity), which typically present with hives (urticaria), itching, and flushing. The patient's symptoms of low back pain and fever point towards a hemolytic reaction, not an allergic one.
Option D: While checking the patient's identification against the blood bag is a critical part of the verification process to prevent a reaction, it is not the first action once a reaction has started. The immediate priority is the clinical intervention to stop the harm.

Visual 1: Flowchart - Step-by-step nursing actions for a suspected blood transfusion reaction, starting with 'Stop the transfusion' and branching to notification, monitoring, and supportive care.
Visual 2: Infographic - A table comparing different types of transfusion reactions (hemolytic, allergic, febrile non-hemolytic), their key signs/symptoms, and priority nursing interventions for each.

Clinical Relevance

Nursing practice connection: Use the key finding related to Management of Acute Blood Transfusion Reactions to guide bedside assessment, documentation, and the next nursing action.
Rapid recognition of a transfusion reaction and immediately stopping the infusion are critical nursing skills that can prevent severe morbidity (like acute renal failure) and mortality.
Nurses are the final safety check in the transfusion process. This scenario underscores the importance of meticulous patient and blood product identification before administration to prevent such reactions.
What if? If the patient only reported a new onset of hives and itching with no other symptoms, the nurse's first action would still be to stop the transfusion. However, the underlying cause would be suspected as a milder allergic reaction, and the subsequent treatment would focus on antihistamines rather than the aggressive fluid and renal support needed for a hemolytic reaction.

How to Approach the Question

First, identify the clinical scenario: a patient is developing acute symptoms during a blood transfusion.
Next, analyze the specific symptoms provided: chills, low back pain, and fever. Recognize these as classic, severe signs of an acute hemolytic reaction, a medical emergency.
The question asks for the 'first action,' which indicates a priority-setting question. In emergencies, the primary principle is to remove the offending agent to prevent further harm.
Evaluate the options based on this principle. Stopping the transfusion is the only option that directly removes the cause of the life-threatening reaction.
Rule out the other options by assessing their appropriateness. Slowing the rate is inadequate, administering an antihistamine treats the wrong type of reaction, and checking the ID is an administrative/investigative step, not an immediate clinical intervention.

Concept Tested & Keywords

Concept Tested: Management of Acute Blood Transfusion Reactions
Stem keywords: blood transfusion, chills, low back pain, fever, nurse's first action
Lead-in keywords: first action
Clinical cues: The combination of chills, low back pain, and fever during a blood transfusion strongly indicates a severe, acute hemolytic reaction.
Negative lead-in flag: false

QcGUO1c1HcaT2XUgbfRCOL