One Hour After Starting a Unit of Packed Red Blood $\degree$

question 19

Multiple Choice

One hour after starting a unit of packed red blood cells, a nurse observes that a patient receiving the transfusion is reporting flank pain and has a temperature of 101.8 $\degree$ F (38.8 $\degree$ C) .The nurse's first action should be to:

• A)Assess the patient for signs of rash, hives, or angioedema.
• B)Confirm that the name on the label on the blood transfusion matches the patient's armband.
• C)Medicate the patient with acetaminophen that is ordered prn for pain or fever.
• D)Stop the transfusion and maintain IV access with normal saline.

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