Ati lpn med surg proctored exam (blood immune test)
A nurse is caring for a patient receiving a transfusion and assesses that the patient is wheezing and is complaining of back pain. Which nursing action should take place after stopping the transfusion?
Explanation & Rationale
A. Administer heparin: Heparin is an anticoagulant and is not the indicated treatment for a transfusion reaction. B. Notify the charge nurse: While notification is necessary, it is not the immediate priority to stabilize the patient's intravenous access or physical condition. C. Raise the patient's head: This may help with breathing, but it is not the standard priority action over maintaining IV access for emergency meds. D. Discontinue the intravenous (IV) transfusion: Once the reaction is noted, the transfusion is stopped. The nurse must then disconnect the blood tubing and hang normal saline with new tubing to keep the vein open for emergency medications.
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