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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Related Questions
Correct Answer is C
Explanation
A) Incorrect: Fresh Frozen Plasma (FFP) is not the appropriate blood product for immediate volume replacement. It contains clotting factors and is used to manage bleeding disorders.
B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction and do not provide volume replacement.
C) Correct: Packed Red Blood Cells (PRBCs) contain red blood cells and are used for volume replacement in clients with acute blood loss or anemia.
D) Incorrect: Albumin is used for volume expansion in cases of hypoalbuminemia and fluid resuscitation in certain situations, but PRBCs are more effective for rapid volume replacement.
Correct Answer is A
Explanation
A: Notifying the healthcare provider is an important step, but it is not the immediate priority. The nurse's first action should be to address the adverse reaction to prevent further harm to the client.
B: While administering antipyretics may help lower the client's fever, it does not address the underlying cause of the symptoms, which is the transfusion reaction. The priority is to stop the reaction from progressing.
C: Preparing to administer a diuretic would be appropriate if fluid overload was the primary concern. However, in the case of a transfusion reaction, the priority is to stop the transfusion to halt the reaction.
D: Discontinuing the blood transfusion immediately is the priority action because it stops the exposure to the blood product that is causing the reaction. Once the transfusion is stopped, further interventions can be assessed and implemented.
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