Fundamentals of Nursing Q 469
Packed red blood cells have been prescribed for a client with low hemoglobin and hematocrit levels. The nurse takes the client’s temperature before hanging the blood transfusion and records 100.8 °F. Which action should the nurse take?
A. Give an antipyretic and begin the transfusion.
B. Proceed with the transfusion.
C. Administer an antihistamine and begin the transfusion.
D. Delay hanging the blood and inform the physician.
Correct Answer: D. Delay hanging the blood and inform the physician.
If the patient has a temperature higher than 100 ° F, the unit of blood should be hung and delayed until the physician is notified and has the opportunity to give further orders. Fever and/or chills are most commonly associated with a febrile, non-hemolytic reaction, however; they can also be the first sign of a more serious acute hemolytic reaction, TRALI, or septic transfusion reaction.
Option A: Giving an antipyretic would require a physician’s order. All cases of suspected reactions should prompt immediate discontinuation of the transfusion and notification of the blood bank and treating clinician. A clerical check should be performed by examining the product bag and confirming the patient’s identification. The patient’s vital signs should be monitored and recorded at 15-minute intervals.
Option C: Administering an antihistamine is incorrect since the administration of the medicine will need the physician’s prescription. Treatment of specific transfusion reactions is most often supportive. For example, antihistamines (such as diphenhydramine) can be given for a mild allergic reaction, or an antipyretic can be given for a nonhemolytic febrile transfusion reaction.
Option B: The decision to administer the blood is not within the scope of nurse practice. Currently, guidelines for transfusion of red blood cells (RBC), generally follow a restrictive threshold. While there is some variation in the number for the threshold, 7 g/dL is an agreed-upon value for asymptomatic healthy patients.