When a transfusion reaction is suspected, what is the immediate nursing action?

• A. Stop transfusion and maintain IV access with normal saline; notify the blood bank
• B. Continue transfusion at a slower rate
• C. Administer epinephrine
• D. Warm the blood

Answer: (A)

When a transfusion reaction is suspected, the immediate priority is to stop the transfusion and keep the IV line open with normal saline. Halting the infusion stops further exposure to the donor product and helps prevent the reaction from worsening, while the saline maintains circulatory access for fluids and any medications you may need to give. At the same time, notify the blood bank right away so they can identify the implicated unit, begin product withdrawal if needed, and initiate the transfusion reaction protocol. After stopping, follow your facility’s protocol for monitoring the patient, collecting any specimens, and ensuring safety. Continuing the transfusion, giving epinephrine as a routine measure, or warming the blood are not appropriate immediate steps; they can either delay appropriate action or worsen the reaction, and epinephrine is reserved for specific severe reactions after assessment.