While receiving blood transfusion the patient develops chills and headache. What should be the nurse's initia… - GMCH Chandigarh - 2019

GMCH Chandigarh - 2019

Medical & Surgical Nursing

Medium

Appeared in: GMCH Chandigarh - 2019

Explanation

Chills and headache are classic signs of a transfusion reaction, most commonly a febrile non-hemolytic reaction.
The absolute first priority in managing a suspected transfusion reaction is to stop the infusion of the blood product immediately.
This action prevents further exposure to the causative agent (e.g., antigens, bacteria) and is a critical step in preventing the reaction from worsening and potentially becoming life-threatening.

Option A: Notifying the physician is a crucial secondary step. The nurse's immediate, independent action to ensure patient safety by stopping the transfusion takes precedence.
Option C: These are comfort measures that treat symptoms, not the underlying cause. It is dangerous to mask the signs of a progressing reaction while the transfusion continues.
Option D: Slowing the rate is insufficient and unsafe. It allows the offending agent to continue infusing, which can worsen the reaction. The infusion must be stopped completely.

Clinical Relevance

Nursing practice connection: Use the key finding related to Management of Acute Transfusion Reactions to guide bedside assessment, documentation, and the next nursing action.
Prompt recognition and immediate cessation of a blood transfusion are critical nursing skills that prevent patient harm. Delay can lead to severe complications like acute hemolytic reaction, anaphylactic shock, or sepsis, which can be fatal.
Nurses are the frontline defenders during a transfusion; they must be vigilant in monitoring for subtle signs of a reaction, especially within the first 15 minutes of the infusion.
What if? The patient developed only a few hives (urticaria) around the IV site with no other symptoms. The nurse should still stop the transfusion immediately, as this could be the start of an allergic reaction. After notifying the physician, an antihistamine may be ordered. If symptoms resolve, the physician may order the transfusion to be cautiously restarted.

How to Approach the Question

This is a clinical priority question, asking for the 'initial action'.
First, identify the core clinical problem: The patient is showing signs (chills, headache) of an acute complication during a blood transfusion.
Next, evaluate the options based on the principle of patient safety. The highest priority is to remove or stop the source of harm.
Analyze the actions: 'Stopping the transfusion' is the only option that directly removes the potential cause of the problem.
Actions like notifying the physician or providing comfort measures are important but are secondary to stopping the harmful infusion.
Therefore, select the option that provides the most immediate and direct intervention to protect the patient.

Concept Tested & Keywords

Concept Tested: Management of Acute Transfusion Reactions
Stem keywords: blood transfusion, chills, headache, initial action
Lead-in keywords: initial action
Clinical cues: The development of new symptoms (chills, headache) during a procedure (blood transfusion) signals an acute complication requiring immediate intervention.

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E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 77-79

E6 Nursing Fundamentals Taylor p. 830-832