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) Correct: Pre-medicating the client with antihistamines before the transfusion can help prevent or minimize allergic transfusion reactions in clients with a history of severe allergies. Antihistamines block histamine release, reducing the risk of allergic symptoms.
B) Incorrect: Administering the blood transfusion rapidly is not a preventive measure for allergic transfusion reactions. In fact, rapid administration may increase the risk of adverse reactions.
C) Incorrect: Warming the blood product before administration is important to prevent hypothermia but is not directly related to preventing allergic transfusion reactions.
D) Incorrect: Monitoring the client's vital signs during the transfusion is a standard practice, but it is not the primary intervention for preventing allergic transfusion reactions. Pre-medication with antihistamines is a more targeted approach.
Correct Answer is C
Explanation
A. Platelets should be infused rapidly, typically over 30 to 60 minutes, to prevent clotting and ensure effectiveness.
B. A specialized platelet administration set with a filter should be used, not a standard IV infusion set.
C. Although ABO compatibility is less critical for platelets than for red blood cell transfusions, compatibility should still be verified to reduce the risk of reactions.
D. Platelets should not be warmed; they should be stored at room temperature and gently agitated to prevent clumping.
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