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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Notify the healthcare provider immediately to obtain a blood transfusion order – This is the priority action because the client’s hemoglobin level of 8 g/dL, along with symptoms of hypoxia, indicates a need for urgent medical intervention. Obtaining an order for a transfusion is crucial for addressing the underlying issue of low hemoglobin and associated hypoxia.
B: Administer supplemental oxygen to the client to improve oxygenation – While this action is important, it is not the first step. The low hemoglobin indicates a need for a transfusion, and notifying the provider can lead to quicker treatment.
C: Initiating IV access with a large-bore catheter is an important step in preparation for a possible blood transfusion, but it is not the first action. The client's current symptoms must be managed promptly.
D: Ambulation may be contraindicated post-major surgery, especially when the client is symptomatic. It could exacerbate the client's condition and is not the immediate priority in this scenario.
Correct Answer is A
Explanation
A) Correct: Fresh Frozen Plasma (FFP) contains various clotting factors and is used to manage clotting factor deficiencies, including those related to liver disease.
B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction but do not primarily address clotting factor deficiencies caused by liver disease.
C) Incorrect: Cryoprecipitate is derived from FFP and contains concentrated fibrinogen and other clotting factors. It may be used in some cases of liver disease, but FFP is the more common choice for managing these conditions.
D) Incorrect: Packed Red Blood Cells (PRBCs) are used to improve oxygenation in anemic clients and are not the primary treatment for clotting factor deficiencies related to liver disease.
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