Editing Reduction of Risk Potential – LPN Practice Questions (section)

==Question 7==
The nurse is caring for a client receiving a unit of packed red blood cells. Fifteen minutes into the transfusion the client develops hives, itching, and reports feeling flushed. What should the nurse do first?
# Stop the transfusion and keep the intravenous line open with normal saline.
# Slow the rate and give the client an antihistamine that was ordered as needed.
# Apply lotion to the skin and continue the transfusion.
# Take the client's temperature and document the finding.

'''Answer:''' Option 1. Stop the transfusion and keep the intravenous line open with normal saline.

''Rationale:'' Any suspected transfusion reaction requires stopping the transfusion first, then maintaining the intravenous line with normal saline through new tubing so that no more blood enters, and notifying the registered nurse, provider, and blood bank. Assessment and medication follow after the transfusion is stopped. Options 2 and 3 continue exposure to the product. Option 4 delays the priority action, although vital signs are obtained right after stopping.