A nurse suspects an acute transfusion reaction and has stopped the blood product. Which action should the nurse take next?
1Discard the blood bag and tubing immediately so no contaminated material remains at the bedside.
2Restart the blood slowly after the temperature decreases, without contacting the blood bank.
3Maintain IV access with normal saline using new tubing and follow the facility reaction protocol.✓ Correct answer
4Administer an antipyretic and wait one hour before reporting the reaction.
Explanation
After stopping a suspected transfusion reaction, maintain IV access with normal saline using new tubing and follow the facility reaction protocol (option 3), including required notifications, assessment, specimens, and return of the blood bag and tubing. Do not discard the blood product, restart it independently, or delay reporting while treating symptoms.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Acute transfusion reaction.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical Practice GuideFor Acute transfusion reaction, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
Transfusion Reaction — An adverse response to a blood product.
Packed Red Blood Cells — A blood product used to increase oxygen-carrying capacity.
Normal Saline — An isotonic crystalloid compatible with many blood administration protocols.