A client receiving a blood transfusion develops sudden chest pain, dyspnea, and a productive cough with pink, frothy sputum. The nurse suspects a severe transfusion reaction. What is the nurse's immediate action?

Raise the head of the client's bed and administer oxygen.

Obtain a sputum sample for culture and sensitivity testing.

Administer a diuretic to relieve pulmonary congestion.

Discontinue the blood transfusion and remove the IV catheter.

Answer and Explanation

The Correct Answer is A

A) Raising the head of the client's bed and administering oxygen is the immediate action to improve oxygenation and relieve respiratory distress in a client experiencing potential pulmonary edema, as evidenced by the pink, frothy sputum.

B) Obtaining a sputum sample for culture and sensitivity testing may be important to assess for infection, but it is not the nurse's immediate action in response to a severe transfusion reaction.

C) Administering a diuretic may help with pulmonary congestion, but it is not the nurse's immediate action in response to a severe transfusion reaction. The priority is to improve oxygenation.

D) Discontinuing the blood transfusion and removing the IV catheter is important, but the immediate action to address the client's respiratory distress is to raise the head of the bed and administer oxygen. Stopping the transfusion can follow after the client's respiratory status stabilizes.

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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.

A. Fresh Frozen Plasma (FFP) B. Platelets C. Cryoprecipitate D. Packed Red Blood Cells (PRBCs)

Correct Answer is A

Explanation

A) Correct: Fresh Frozen Plasma (FFP) contains various clotting factors and is used to treat clotting factor deficiencies such as those found in coagulopathies or liver disease.

B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction, not clotting factor deficiencies.

C) Incorrect: Cryoprecipitate is derived from FFP and contains concentrated fibrinogen and other clotting factors. It is used for specific clotting factor deficiencies but is not the primary treatment for clotting factor deficiencies in general.

D) Incorrect: Packed Red Blood Cells (PRBCs) are used to treat anemia and improve oxygenation but do not address clotting factor deficiencies.

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A client receiving a blood transfusion develops sudden chest pain, dyspnea, and a productive cough with pink, frothy sputum. The nurse suspects a severe transfusion reaction. What is the nurse's immediate action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a history of severe allergic reactions and is scheduled to receive a blood transfusion. What intervention should the nurse implement to prevent an allergic transfusion reaction in this client?

Correct Answer is A

Explanation

A nurse is preparing to administer a blood product to a client with a clotting factor deficiency. Which blood product should the nurse anticipate administering?

Correct Answer is A

Explanation

A nurse is preparing to administer a blood component to a client. Which blood component is responsible for promoting clot formation and controlling bleeding?

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