A client is receiving a blood transfusion of packed red blood cells. Fifteen minutes into the infusion, the client develops a sudden fever, chills, and flank pain. The nurse suspects an acute hemolytic reaction. After stopping the transfusion, what is the nurse's NEXT PRIORITY action?
- AObtain a urine specimen for hemoglobinuria.
- BMaintain a patent IV line with normal saline.
- CNotify the blood bank and the healthcare provider.
- DAdminister ordered antipyretics and antihistamines.
Show answer & explanationAnswer & explanation
Correct answer: B. Maintain a patent IV line with normal saline.
After stopping the transfusion for a suspected acute hemolytic reaction, the immediate priority is to maintain a patent IV line. This allows for continued venous access to administer medications (e.g., diuretics, vasopressors) and IV fluids (e.g., normal saline) to support renal function and prevent shock, which are critical in managing this severe reaction. The other actions are important but follow maintaining IV access.
Why the other options are wrong
- A. Obtaining a urine specimen is part of the workup but comes after securing IV access.
- C. Notifying the blood bank and provider is critical, but securing the IV line is a hands-on, immediate action for client stability.
- D. Administering medications is important, but maintaining IV access is needed to give them.
Acute Hemolytic Reaction Management
An acute hemolytic transfusion reaction is a severe, life-threatening immune response to incompatible blood. After stopping the transfusion, the priority is to maintain IV access, usually with normal saline, to support circulation, prevent renal damage, and allow for rapid administration of emergency medications.
- Life-threatening immune reaction.
- Signs: fever, chills, flank pain.
- Stop transfusion immediately.
- Maintain IV access with NS.
Memory trick: Transfusion reaction? Stop, then keep that line flowing!