The first response of a nurse on noticing suspected blood transfusion reaction should be?

GMCH Chandigarh - 2022

Medical & Surgical Nursing

Easy

Appeared in: GMCH Chandigarh - 2022

Explanation

The absolute first priority in managing a suspected transfusion reaction is to immediately stop the infusion.
This action is critical because it prevents the patient from receiving more of the blood component that is causing the adverse reaction.
The severity of many transfusion reactions, especially acute hemolytic reactions, is directly related to the volume of incompatible blood infused.
All other nursing actions, while essential, are performed only after the transfusion has been stopped to ensure patient safety.

Option A: Informing the patient's attendants is not the immediate priority. The nurse's primary responsibility is to the patient's direct clinical safety during an emergency.
Option B: While notifying the doctor is a critical step, it should be done immediately after stopping the transfusion. The nurse must first intervene to prevent further harm.
Option D: Monitoring urine output is an important assessment to detect complications like acute kidney injury due to hemolysis, but it is not the first intervention.

Clinical Relevance

Nursing practice connection: Knowing Priority nursing action for a suspected blood transfusion reaction helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Prompt recognition and immediate cessation of a transfusion are critical nursing skills that can prevent life-threatening complications such as anaphylactic shock, acute hemolytic reaction, or Transfusion-Related Acute Lung Injury (TRALI).
Nurses must be vigilant, especially during the first 15 minutes of a transfusion, as this is when most severe reactions occur.
What if? If the patient only develops mild urticaria (hives) with no other symptoms, the physician might order to slow the transfusion and administer an antihistamine. However, the safest initial action is always to stop the infusion, assess the patient, and then consult the physician.

How to Approach the Question

First, identify that this is a priority-based question asking for the 'first response'. These questions test your ability to prioritize nursing actions based on patient safety.
Analyze the clinical scenario: a 'suspected blood transfusion reaction' is a potential emergency.
Apply the principle of patient safety: the first action should always be to remove or stop the source of harm.
Evaluate the options based on this principle. 'Stop the transfusion' is the only option that directly intervenes to prevent further harm.
The other options ('Call the doctor', 'Monitor urine output', 'Inform attendants') are all necessary actions, but they are secondary to stopping the infusion.

Concept Tested & Keywords

Concept Tested: Priority nursing action for a suspected blood transfusion reaction.
Stem keywords: first response, nurse, suspected blood transfusion reaction
Lead-in keywords: first
Negative lead-in flag: false

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