High School

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client's temperature increases to 39.1ºC (102.4ºF). Which of the following actions should the nurse take first?

a) Slow the infusion rate of the blood.
b) Administer an antipyretic medication.
c) Obtain a blood culture from the client.
d) Notify the provider.

Answer :

Final answer:

The first action a nurse should take when a client's temperature increases significantly during a transfusion of packed RBCs is to notify the healthcare provider, as it can indicate a potentially serious transfusion reaction. The correct answer is d).

Explanation:

Transfusion reactions are defined as adverse events associated with the transfusion of whole blood or one of its components. These may range in severity from minor to life-threatening. The first action a nurse should take when a client's temperature increases to 39.1ºC (102.4ºF) during a transfusion of packed RBCs. The first action to take in such a situation is to notify the provider.

This is because a sudden increase in temperature can indicate a transfusion reaction, which may require immediate medical intervention to prevent more serious complications. The other listed actions, such as slowing the infusion rate, administering an antipyretic medication, and obtaining a blood culture, might be subsequent steps based on the provider's assessment and orders.

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