NCLEX-RNPharmacological and Parenteral TherapiesMedium
A client is scheduled to receive a unit of packed red blood cells (PRBCs). The client's temperature is 100.8°F (38.2°C) orally. All other vital signs are within normal limits. What is the most appropriate nursing action?
- AAdminister acetaminophen and proceed with the transfusion in 30 minutes.
- BAdminister the PRBCs as ordered and recheck the temperature in 30 minutes.
- CNotify the healthcare provider before initiating the transfusion.
- DProceed with the transfusion, but administer it at a slower rate.
Show answer & explanationAnswer & explanation
Correct answer: C. Notify the healthcare provider before initiating the transfusion.
A fever, even low-grade, prior to a blood transfusion could mask an early sign of a transfusion reaction, as fever is a common symptom of such reactions. The nurse should notify the healthcare provider before initiating the transfusion to determine if it should be delayed or if antipyretics should be administered.
Why the other options are wrong
- A. Administering acetaminophen without a provider's order for a pre-transfusion fever is not within the nurse's scope, and the decision to proceed still needs MD input.
- B. Administering PRBCs with a fever risks masking a transfusion reaction and is unsafe.
- D. Slowing the rate does not address the risk of masking a reaction or the cause of the fever.
Pre-Transfusion Fever
A pre-existing fever before a blood transfusion can mask the early signs of a transfusion reaction. The nurse must notify the provider to determine the appropriate course of action.
- Fever is a common sign of acute transfusion reactions.
- Masking a reaction can delay intervention, increasing risk.
- Provider decides whether to proceed, delay, or pretreat.
- Antipyretics may be ordered before transfusion for specific reasons.
Memory trick: Fever Before Blood? Call the Doc, Don't Proceed!