Question

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client's temperature increases to 39.1 C (102.4 F). Which of the following actions should the nurse take first?

A) obtain urine specimen
B) administer diphenhydramine
C) stop the infusion
D) notify the charge nurse"

Answer 1

C) stop the infusion. A nurse should stop the infusion when a client's temperature increases during a transfusion of packed RBCs.

Step-by-step explanation:

When a client's temperature increases to 39.1°C (102.4°F) during a transfusion of packed RBCs, the nurse should take the action of stopping the infusion first.

Transfusion reactions, including febrile nonhemolytic reactions, can occur during blood transfusions. A temperature increase of this magnitude could indicate a transfusion reaction. Stopping the infusion is the first step in managing such reactions.

After stopping the infusion, the nurse should then assess the client for other signs and symptoms of a transfusion reaction, such as chills, rash, or dyspnea. The client's vital signs should also be closely monitored. The charge nurse should be notified if necessary.