NCLEX-RN (Registered Nurse) Practice Exam · Question
A client receiving a blood transfusion begins to develop chills, fever, and lumbar pain 15 minutes after the transfusion started. What is the nurse's immediate priority action?
These symptoms are indicative of an acute hemolytic transfusion reaction, which is life-threatening. The immediate priority is to stop the transfusion to preven
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Question: A client receiving a blood transfusion begins to develop chills, fever, and lumbar pain 15 minutes after the transfusion started. What is the nurse's immediate priority action?
Answer options:
- Slow down the transfusion rate.
- Administer antipyretics and analgesics. ✅ Stop the transfusion immediately.
- Obtain a urine specimen for analysis.
Correct answer: Stop the transfusion immediately.
Explanation: These symptoms are indicative of an acute hemolytic transfusion reaction, which is life-threatening. The immediate priority is to stop the transfusion to prevent further incompatibility and client harm. All other actions are secondary.
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