Question

A patient receiving a unit of red blood cells suddenly develops shortness of breath, chills, and fever. Following patient assessment, what is the nurse's initial action?

a. Reassure the patient that this is an expected reaction.
b. Notify the physician while a peer monitors the blood transfusion.
c. Discontinue the infusion of packed cells.
d. Decrease the infusion rate, and reassess the patient in 15 minutes.

Answer 1

The nurse's initial action when a patient develops signs of a possible hemolytic transfusion reaction should be to discontinue the infusion of packed cells (option c) immediately, as these symptoms can be indicative of a severe and potentially fatal response.

Step-by-step explanation:

If a patient receiving a unit of red blood cells suddenly develops shortness of breath, chills, and fever, the initial action of the nurse should be to discontinue the infusion of packed cells. This set of symptoms can indicate a hemolytic transfusion reaction (HTR), which is a potentially life-threatening condition. The nurse should then follow proper emergency protocols, which include notifying the physician and treating the symptoms.

A hemolytic transfusion reaction occurs when the patient's immune system attacks the transfused red blood cells, leading to their destruction. This can cause a systemic inflammatory response that can result in shock, organ failure, or even death if not quickly identified and managed. The symptoms such as fever, chills, and difficulty breathing, are signs of this adverse reaction. Thus, it is critical to stop the transfusion immediately to prevent further harm.