A nurse is caring for a client who has a prescription for 1 unit of packed RBCs. Five minutes after beginning the transfusion, the client becomes febrile with chills. After stopping the transfusion, which of the following actions should the nurse take?
Explanation & Rationale
A. Place the blood bag in a biohazard bag before discarding: While proper disposal of blood products is important, the immediate priority after stopping the transfusion is to ensure the patient's safety and document the reaction. The blood bag should be sent for analysis, but this action does not address the immediate next steps for patient care. B. Administer epinephrine subcutaneously: This is not the first action unless the client is experiencing an anaphylactic reaction, which is not indicated in this scenario. The reaction described is more consistent with a febrile non-hemolytic transfusion reaction. C. Document the reaction in the medical record: This is the most appropriate action following the cessation of the transfusion. Accurate documentation of the reaction ensures that all healthcare providers are informed of the client’s status and the incident, which is critical for ongoing care and safety. D. Infuse 500 ml. lactated Ringer's IV: While providing IV fluids may be necessary to maintain venous access or manage symptoms, the immediate action after stopping the transfusion should focus on documenting the reaction and notifying the healthcare provider, as appropriate interventions can then be determined.