You are collecting vital signs for a patient who started a blood transfusion five minutes ago and notice a temperature increase from 98.2°F to 101.3°F. What action should you take next?

The correct action in this scenario is to activate transfusion reaction protocol. When a patient experiences a temperature increase shortly after starting a blood transfusion, it raises the concern for a possible transfusion reaction, such as a febrile non-hemolytic reaction or other more serious complications. The fundamental principle in nursing is to prioritize patient safety, and recognizing early signs of a transfusion reaction is vital.

Activating the transfusion reaction protocol prompts the healthcare team to take immediate and appropriate measures to ensure the patient's safety, potentially including stopping the transfusion, maintaining venous access, monitoring vital signs more closely, and gathering necessary data for further evaluation. This action also ensures that the healthcare provider is alerted and that necessary protocols are followed promptly, which can be critical in preventing severe complications.

While continuing to monitor the patient might seem logical, it does not address the potential risk associated with the sudden change in temperature. Contacting the physician is also necessary eventually, but the first critical step is to respond to the signs of a possible transfusion reaction. Administering antipyretics may address the fever but does not resolve the underlying concern for a transfusion reaction; thus, it would be inappropriate without first stopping the transfusion and following the proper protocol