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Question:
A nurse is monitoring a patient during a transfusion. The patient acutely develops flank and chest pain accompanied by hypotension, respiratory distress, and tachycardia. The nurse notes scant brownish discolored urine in the patient’s foley bag. Which of these answer choices correctly describes both the nurse’s first action as well as the name of this patient’s transfusion reaction?
A
Stop the transfusion immediately due to hemolysis.
explanation
The first course of action with any adverse reaction during the administration of blood produces is to immediately stop the infusion. The symptoms and signs described in this patient point to hemolysis likely due to ABO incompatibility. Allergic reactions may also present with swelling, flushing, tachycardia, and respiratory distress, but there will be no urinary changes (amount, color, etc.) present as there will be with hemolysis.
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