NCLEX-PN Exam Practice

Category - Shock

You determine that the patient you are caring for is having a transfusion reaction. You stop the blood immediately. Which action would you take next?
  1. Notify a physician.
  2. Determine the patient’s white blood cell count.
  3. Administer normal saline at KVO.
  4. Administer normal saline bolus.
Explanation
Answer: C - The nurse should start normal saline at KVO for this patient to keep the IV open. Then the nurse should notify the physician of the reaction. The physician may order a white blood cell count or normal saline bolus, but the nurse should not initiate either without an order.
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