Case study: Client receiving packed red blood cells. A 63-year-old starts a blood transfusion. Fifteen minutes later the client reports chills, low back pain, and a feeling of doom. Which finding in this case is the highest priority for the nurse to address first?

Question

Accepted Answer

B. suspected acute transfusion reaction — In this case, the highest-priority finding is suspected acute transfusion reaction because it most directly threatens safety or signals clinical deterioration.

Answer

A. sleepiness after diphenhydramine

Answer

C. hunger before dinner

Answer

D. mild increase in temperature from warm blankets