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    Swedish Institute College Of Health Sciences Medical Surgical Proctored Exam

    A nurse is caring for a client who is receiving a blood transfusion and exhibits signs of a transfusion reaction. What is the priority intervention the nurse should take?

    Explanation & Rationale

    Rationale: A. Using the same tubing may allow residual blood to continue entering the patient, which could worsen the reaction. Proper procedure requires new tubing to safely infuse saline. B. Although notifying the provider and documenting are important, the priority is to stop the transfusion immediately to prevent further exposure and reduce risk of life-threatening complications. C. Stopping the transfusion prevents further exposure to the incompatible blood product. Maintaining IV access with saline through new tubing allows for hydration, administration of emergency medications if needed, and collection of samples for evaluation, ensuring patient safety. D. During a transfusion reaction, vital signs should be monitored continuously, not every 30 minutes, to promptly detect rapid changes such as hypotension, tachycardia, or respiratory distress. Continuous assessment is essential to intervene immediately if the patient’s condition deteriorates.

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