A nurse is caring for a client who develops urticaria (hives) and itching during a blood transfusion. The nurse suspects an allergic transfusion reaction. What is the appropriate nursing action?

A) Incorrect: A slight increase in blood pressure is not a significant vital sign alteration that requires immediate reporting before initiating the transfusion. It could be related to various factors, such as anxiety or pain.

B) Incorrect: A respiratory rate of 22 breaths per minute is within the normal range for an adult and does not require immediate reporting before starting the transfusion.

C) Incorrect: A decrease in heart rate from 88 to 72 beats per minute is not a critical vital sign alteration. As long as the heart rate remains within the client's baseline range, it does not need immediate reporting.

D) Correct: An elevated temperature of 38.5°C (101.3°F) may indicate a fever, which could be a sign of an infection or an adverse reaction to the transfusion. The nurse should report this vital sign alteration to the healthcare provider before proceeding with the transfusion to determine the appropriate course of action.

A) Stopping the blood transfusion immediately is the nurse's priority action if a transfusion reaction is suspected. This helps prevent further infusion of the potentially incompatible or problematic blood product.

B) Notifying the blood bank is essential to report the suspected transfusion reaction and to facilitate investigation and documentation. However, stopping the transfusion is the first step.

C) Administering antipyretics may help manage the client's fever, but it is not the nurse's priority action when a transfusion reaction is suspected.

D) Placing the client in a supine position with legs elevated is not a priority action when a transfusion reaction is suspected. The priority is to stop the transfusion and assess the client's vital signs and symptoms.