A client develops respiratory distress and chest pain during a blood transfusion. The nurse suspects a transfusion-related acute lung injury (TRALI). What is the nurse's priority intervention?

Administering oxygen via a non-rebreather mask.

Discontinuing the blood transfusion immediately.

Elevating the client's feet and lowering the head.

Administering diuretics to manage fluid overload.

Answer and Explanation

The Correct Answer is A

A) Correct: The client's symptoms of respiratory distress and chest pain indicate a potential transfusion-related acute lung injury (TRALI), a severe transfusion reaction. The nurse's priority intervention is to administer oxygen via a non-rebreather mask to improve oxygenation.

B) Incorrect: Discontinuing the blood transfusion immediately is necessary in suspected cases of TRALI, but it is not the priority intervention. First, the nurse should provide immediate respiratory support by administering oxygen.

C) Incorrect: Elevating the client's feet and lowering the head (Trendelenburg position) is not indicated for TRALI. It may be used for clients in shock, but the priority is to manage the client's respiratory distress and chest pain.

D) Incorrect: Administering diuretics is not the priority intervention for TRALI. TRALI is caused by a reaction to plasma components, not fluid overload, and diuretics may not address the underlying cause.

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Correct Answer is C

Explanation

A. Notifying the healthcare provider is important but should be done after stopping the transfusion to prevent further reaction.
B. Administering acetaminophen does not address the underlying cause of the reaction and should not be the priority.
C. Stopping the transfusion and disconnecting the IV tubing is the first priority to prevent further exposure to the incompatible blood product, which could lead to a life-threatening hemolytic reaction.
D. Infusing normal saline is appropriate to maintain hydration, but it should be done after stopping the transfusion.

A. Obtain the client's informed consent for the blood transfusion. B. Confirm the client's blood type and Rh factor with the blood bank. C. Administer pre-medication to prevent transfusion reactions. D. Assess the client's blood pressure and heart rate.

Correct Answer is ["A","B","D"]

Explanation

A) Obtaining the client's informed consent is a critical step before any medical procedure, including blood transfusions. This ensures the client understands the risks and benefits of the transfusion and gives their consent willingly.

B) Confirming the client's blood type and Rh factor with the blood bank is essential to prevent transfusion reactions. Mismatching blood types can lead to severe transfusion reactions and is a crucial step in the transfusion process.

C) Administering pre-medication to prevent transfusion reactions is not a standard practice. However, the nurse should assess the client for any risk factors or history of previous transfusion reactions to take appropriate precautions.

D) Assessing the client's blood pressure and heart rate is an important part of the overall assessment before the blood transfusion.

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A client develops respiratory distress and chest pain during a blood transfusion. The nurse suspects a transfusion-related acute lung injury (TRALI). What is the nurse's priority intervention?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who just received a blood transfusion. The client complains of back pain, fever, and chills. What action should the nurse take first?

Correct Answer is C

Explanation

A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client with severe anemia. Before starting the blood transfusion, the nurse should:

Correct Answer is ["A","B","D"]

Explanation

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