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.
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.
Questions
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect: Transfusing whole blood increases the risk of adverse reactions and is not commonly used in modern transfusion practices. Whole blood is usually separated into its individual components for transfusion.
B) Incorrect: Fresh frozen plasma (FFP) contains various clotting factors and is used primarily to treat bleeding disorders and coagulopathies, not to prevent transfusion reactions.
C) Correct: Packed red blood cells (PRBCs) contain primarily red blood cells without significant amounts of plasma, white blood cells, or platelets. For clients with a history of transfusion reactions, PRBCs are the most suitable blood component to minimize the risk of future reactions.
D) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction but do not provide the main benefit of minimizing the risk of future transfusion reactions as PRBCs do.
Correct Answer is ["A","B","D"]
Explanation
A) Obtaining the client's informed consent is a critical step before any medical procedure, including blood transfusions. This ensures the client understands the risks and benefits of the transfusion and gives their consent willingly.
B) Confirming the client's blood type and Rh factor with the blood bank is essential to prevent transfusion reactions. Mismatching blood types can lead to severe transfusion reactions and is a crucial step in the transfusion process.
C) Administering pre-medication to prevent transfusion reactions is not a standard practice. However, the nurse should assess the client for any risk factors or history of previous transfusion reactions to take appropriate precautions.
D) Assessing the client's blood pressure and heart rate is an important part of the overall assessment before the blood transfusion.
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