Question

What immediate nursing intervention will you take in case of blood reaction?
1. Inform the physician
2. Inform blood bank
3. Monitor vital signs
4. Stop the transfusion immediately and monitor vital signs

Answer 1

Correct Answer - Option 4 : Stop the transfusion immediately and monitor vital signs

Concept:

• Blood transfusion (BT) therapy involves transfusing whole blood or blood components (specific portion or fraction of blood lacking in the patient). 

Explanation:

If a blood reaction occurs then the first and foremost nursing intervention is to stop the transfusion immediately and monitor vital signs. These can be achieved by the following steps:

1. Start IV line (0.9% NaCl) - it is an intravenous isotonic solution with an osmolarity of about 308 mOsm/l.
2. Place the patient in a Fowler’s position (a semi-sitting position (45-60 degrees) and may have knees either bent or straight).
3. If the patient is Short of Breath, immediately administer O2 therapy
4. The nurse must remain with the patient and check vital symptoms at a regular time interval.
5. Immediately Inform the physician.
6. The nurse is then required to prepare emergency drugs like antihistamines, vasopressors, fluids, and steroids as per the physician’s order