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 B

Explanation

A) Incorrect: Fever and chills during a blood transfusion may be signs of a febrile transfusion reaction, not an allergic reaction. The nurse should provide information specific to preventing allergic reactions.

B) Correct: Itching, rash, and facial swelling are common signs of an allergic transfusion reaction. The nurse should instruct the client to notify the healthcare provider immediately if they experience these symptoms.

C) Incorrect: A brief period of increased heart rate after the transfusion may be normal, but it is not specific to preventing an allergic transfusion reaction. The nurse should focus on providing information about allergic reaction symptoms.

D) Incorrect: Lower back pain is not typically associated with allergic transfusion reactions. The nurse should provide information about symptoms that indicate an allergic reaction, such as itching, rash, and facial swelling.

A. Verify the client's identity and blood type with two unique identifiers. B. Confirm the expiration date of the blood product. C. Assess the client's vital signs, including temperature, pulse, and blood pressure. D. Obtain informed consent from the client for the blood transfusion.

Correct Answer is A

Explanation

A) Correct: The nurse should verify the client's identity and blood type with two unique identifiers, such as asking the client to state their full name and date of birth and comparing it to their identification band. This step ensures that the correct blood product is administered to the right client, promoting safety.

B) Incorrect: Confirming the expiration date of the blood product is important but not the first step in ensuring client safety during a blood transfusion. The nurse should first verify the client's identity and blood type.

C) Incorrect: Assessing the client's vital signs is essential, but it is not the first action to be taken. Verifying the client's identity and blood type is the priority before starting the transfusion.

D) Incorrect: Obtaining informed consent from the client is crucial but not the first action to be taken. The nurse should first verify the client's identity and blood type before seeking consent for the transfusion.

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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 caring for a client who is about to receive a blood transfusion. What information should the nurse provide to the client to prevent an allergic transfusion reaction?

Correct Answer is B

Explanation

A nurse is preparing to initiate a blood transfusion for a client. Which action should the nurse take first to ensure client safety?

Correct Answer is A

Explanation

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

A client with blood type AB-positive (AB+) requires a blood transfusion. Which blood types can safely donate to this client?

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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?

A nurse is caring for a client who experienced a mild allergic reaction during a blood transfusion. Which action should the nurse take to prevent future allergic reactions in this client?