Benchmark I Medical-Surgical Nursing Practice Test

The key idea is to act fast to stop the reaction and preserve the patient’s safety. When a suspected transfusion reaction occurs, the immediate priority is to halt the transfusion to stop any ongoing exposure to the problematic product. Keep the IV line open with normal saline to maintain venous access and to be able to administer fluids or medications if needed, using new tubing if possible to avoid continuing the reaction through contaminated lines. Then notify the prescriber and the blood bank so the reaction protocol can be activated, orders can be given for further assessment and testing, and the transfusion event is properly documented. Close monitoring of vital signs helps track how the patient is responding and guides subsequent care, and documenting the event ensures accurate records for treatment, reporting, and future safety considerations. This sequence prioritizes stopping the harmful exposure, maintaining circulation, obtaining expert input, and capturing a complete account of what happened.

Continuing the transfusion would keep exposing the patient to the problematic product, which can worsen the reaction. Simply discarding the bag and starting a saline lock without further action misses critical steps like notifying the team and initiating testing. Increasing the transfusion rate to “flush” the reaction is dangerous and could accelerate harm.