A client receiving a blood transfusion suddenly becomes agitated, dyspneic, and reports a sense of impending doom. The nurse assesses the client and notes jugular vein distention and muffled heart sounds. What action should the nurse take next?

Place the client in a supine position with legs elevated.

Administer oxygen via a non-rebreather mask.

Check the client's temperature and administer antipyretics if necessary.

Stop the blood transfusion and notify the healthcare provider.

Answer and Explanation

The Correct Answer is B

A) Incorrect: Placing the client in a supine position with legs elevated is not appropriate in this situation. The client is showing signs of a potential severe allergic reaction (anaphylaxis) or a transfusion-related acute lung injury (TRALI), and the nurse should prioritize interventions accordingly.

B) Correct: Administering oxygen via a non-rebreather mask is the appropriate immediate action for a client experiencing respiratory distress and muffled heart sounds. This intervention helps improve oxygenation and respiratory function.

C) Incorrect: Checking the client's temperature and administering antipyretics is not indicated as the client's symptoms are not consistent with a fever. The focus should be on respiratory and cardiovascular support.

D) Incorrect: Stopping the blood transfusion is essential, but it is not the immediate action in this situation. The nurse's priority is to address the client's respiratory distress and ensure adequate oxygenation by administering oxygen, as stated in option B. Once the client is stable, the nurse should then notify the healthcare provider about the situation.

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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.

A. Obtain a signed informed consent from the client. B. Confirm the client's blood type and Rh factor with two unique identifiers. C. Ensure that the blood product is properly labeled and has not expired. D. Assess the client's vital signs and baseline laboratory values.

Correct Answer is B

Explanation

A) Incorrect: Obtaining a signed informed consent is an essential step before administering a blood transfusion, but it is not the priority action for preventing a potential complication related to blood compatibility. The nurse should first confirm the client's blood type and Rh factor.

B) Correct: The nurse's priority action is to confirm the client's blood type and Rh factor with two unique identifiers to ensure compatibility between the client and the blood product. This step is crucial for preventing transfusion reactions due to ABO and Rh incompatibility.

C) Incorrect: Ensuring that the blood product is properly labeled and has not expired is important for patient safety but is not the priority action before administering a blood transfusion. The nurse should first confirm the client's blood type and Rh factor.

D) Incorrect: Assessing the client's vital signs and baseline laboratory values is essential, but it is not the priority action for preventing a potential complication related to blood compatibility. The nurse should first confirm the client's blood type and Rh factor.

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A client receiving a blood transfusion suddenly becomes agitated, dyspneic, and reports a sense of impending doom. The nurse assesses the client and notes jugular vein distention and muffled heart sounds. What action should the nurse take next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a platelet transfusion to a client with severe thrombocytopenia. The nurse should:

Correct Answer is C

Explanation

A nurse is preparing to administer a blood transfusion to a client. What is the nurse's priority action to prevent a potential complication related to blood compatibility?

Correct Answer is B

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?

A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?

A client with blood type B-positive (B+) requires a blood transfusion. Which blood types are compatible with this client for a crossmatch?

A nurse is preparing to crossmatch blood for a client who requires a blood transfusion. Which blood component is involved in the crossmatching process?

A nurse is preparing to administer a blood transfusion to a client. Which action should the nurse take before initiating the transfusion?

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A nurse is assessing a client who just received a blood transfusion. The client complains of back pain, fever, and chills. What action should the nurse take first?

A client received a blood transfusion 4 hours ago and now reports feeling lightheaded and dizzy. The nurse notes a drop in blood pressure and an increase in heart rate. What intervention should the nurse implement first?