Delegating, Prioritizing, Triage, and Disaster Practice Test 2025 – Comprehensive Prep

The correct choice highlights a critical first step in managing a transfusion reaction. When a client exhibits signs of a transfusion reaction, such as fever, chills, or rash, the priority nursing intervention is to stop the blood transfusion immediately. This action prevents further exposure to potentially harmful substances in the transfusion product.

In addition to stopping the transfusion, it is essential to maintain venous access for potential administration of saline, which helps to keep the intravenous line open and allows for the administration of emergency medications if needed. This dual action ensures that patient safety is prioritized while the healthcare team can assess the situation, prepare for further intervention, and possibly administer treatments such as antihistamines, corticosteroids, or fluids as necessary.

While checking the client's temperature regularly is important in assessing the extent of the reaction and monitoring the patient's condition, it should occur after the transfusion is halted. Similarly, while informing the family about the client's condition is a vital aspect of patient care, it also comes after ensuring the immediate safety and stabilization of the patient. Thus, maintaining the IV line with saline is the most appropriate nursing intervention in the event of a transfusion reaction.