A client is receiving a blood transfusion, and the nurse suspects a transfusion-related acute lung injury (TRALI) due to sudden respiratory distress. What action should the nurse take to prevent further complications?
Increase the rate of the blood transfusion to complete it quickly.
Administer oxygen via a nasal cannula or face mask.
Place the client in a supine position with legs elevated.
Restart the transfusion with a different blood product.
The Correct Answer is B
A) Incorrect: Increasing the rate of the blood transfusion is not the appropriate action when the client is experiencing respiratory distress. Rapid transfusion may exacerbate the TRALI and lead to further complications.
B) Correct: Administering oxygen via a nasal cannula or face mask is a priority action for a client experiencing respiratory distress. Providing supplemental oxygen can help improve oxygenation and prevent further complications.
C) Incorrect: Placing the client in a supine position with legs elevated is not the appropriate action for a client with respiratory distress. This position may worsen the client's breathing difficulties.
D) Incorrect: Restarting the transfusion with a different blood product is not indicated in the presence of suspected TRALI. The nurse's priority is to manage the client's respiratory distress and discontinue the transfusion if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. AB-positive (AB+) individuals are universal recipients for red blood cells and can safely receive blood from an O-positive (O+) donor.
B. B-negative (B-) individuals require type B or O blood but must receive Rh-negative blood to avoid incompatibility.
C. A-negative (A-) individuals require type A or O blood and must receive Rh-negative blood.
D. AB-negative (AB-) individuals require type AB, A, B, or O blood but must receive Rh-negative blood to prevent a reaction.
Correct Answer is D
Explanation
A. Notifying the healthcare provider is important, but the immediate priority is to stop the transfusion to prevent further exposure to the potential offending blood product.
B. Administering antipyretics addresses fever but does not stop the transfusion, so it does not prevent worsening of a potentially serious reaction.
C. Preparing a diuretic may be appropriate for fluid overload, but the symptoms described (fever, chills, shortness of breath) suggest a transfusion reaction, not just fluid overload. Immediate action is needed to prevent harm.
D. Discontinuing the blood transfusion immediately is the priority action because it prevents additional exposure to the blood product causing the reaction and is the first step in transfusion reaction protocols.
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