Question

During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 f. which intervention should the nurse implement?

Answer 1

The nurse should stop the transfusion, maintain a patent IV line, monitor vitals, notify the doctor, administer antipyretics if ordered, document the incident, collect blood samples, and send the blood bag and tubing to the blood bank for analysis.

Step-by-step explanation:

When a client's temperature increases from 99 to 101.6 degrees Fahrenheit during the infusion of a second unit of packed red blood cells, the nurse should immediately suspect a transfusion reaction and stop the transfusion. The nurse should then maintain a patent intravenous line with saline, monitor the client's vital signs, notify the healthcare provider, and prepare to administer antipyretics as ordered. Furthermore, it is essential to document the incident, the client's response, and any interventions implemented. Guided by protocols, the nurse also collects blood samples for further testing and returns the blood bag and tubing to the blood bank for analysis.