While administering blood products during a surgical procedure, the nurse notes that the patient has spiked a fever to 101 degrees, their skin is flushing and their heart rate has increased. What is the nurse’s first reaction?
Explanation
Answer: D-The nurse’s first action is to stop the transfusion and notify the physician. When giving a blood transfusion, if the patient develops a fever, flushing and becomes tachycardic, they are most likely having a transfusion reaction. The nurse needs to notify the physician who placed the order, as well as the Blood Bank; treat the signs of transfusion reaction; and begin another transfusion, if ordered.
