During a suspected transfusion reaction, what is the first action the nurse should take?

• A. Stop the blood infusion
• B. Notify the physician STAT
• C. Obtain vital signs and assess the patient
• D. Start the new normal saline infusion

Answer: (A)

When a transfusion reaction is suspected, the immediate priority is to stop the blood product right away. Halting the infusion removes the source of the reaction and minimizes further harm to the patient. After stopping, keep the IV line open with isotonic saline to maintain perfusion and to flush any remaining product from the line. Then assess the patient by obtaining vital signs and noting symptoms, and notify the physician STAT so orders and appropriate testing can be initiated. Starting a new normal saline infusion is important for fluid support, but it is not the first action—the reaction must be halted before proceeding with additional steps.