RN Nursing · Blood Transfusion · Practice question
A nurse is assessing a client who is experiencing a blood transfusion reaction. Which of the following actions should the nurse take?
-
Initiate NPO status for the client.
-
Discard the remaining blood in a biohazard container.
-
Change the location of the IV site.
-
✓
Administer 0.9% sodium chloride solution.
Answer & explanation
Correct: Administer 0.9% sodium chloride solution.
During a transfusion reaction, the nurse should immediately stop the transfusion, keep the IV line open with 0.9% sodium chloride (normal saline) using new tubing, and notify the provider. Normal saline maintains venous access for emergency medications and flushes the line without introducing more blood product. NPO is not indicated for a transfusion reaction. The remaining blood and tubing should be returned to the blood bank — not discarded — for analysis to identify the reaction type. The IV site itself does not need to be changed; what matters is discontinuing the blood and using a new line with normal saline. (ATI Blood Transfusion; INS Infusion Therapy Standards.)
Practise Blood Transfusion questions
Work through full question sets with instant rationales, timed exams, and progress tracking.
Start practising freeRelated practice questions
- When preparing to administer a blood transfusion, which of the following actions is essential for the nurse to take to ensure client safety?
- Fifteen minutes after initiation of a packed RBC transfusion, the patient develops chills, flank pain, hypotension, and anxiety. What is the nurse's first action?
- A client is receiving a blood transfusion and develops chills, fever, and low back pain. What is the nurse's first action?
- A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes into the transfusion, the client develops chills, a fever of 101.8°F (38.8°C), and complains of chest tightness and low back pain. Which of the following actions should the nurse take? (Select all that apply)