A client receiving a blood transfusion suddenly develops chills, fever, and lower back pain. The nurse suspects a transfusion reaction. What is the nurse's priority action?
Stop the blood transfusion immediately.
Notify the blood bank to request a new blood unit.
Administer antipyretics to manage the client's fever.
Place the client in a supine position with legs elevated.
The Correct Answer is A
A) Stopping the blood transfusion immediately is the nurse's priority action if a transfusion reaction is suspected. This helps prevent further infusion of the potentially incompatible or problematic blood product.
B) Notifying the blood bank is essential to report the suspected transfusion reaction and to facilitate investigation and documentation. However, stopping the transfusion is the first step.
C) Administering antipyretics may help manage the client's fever, but it is not the nurse's priority action when a transfusion reaction is suspected.
D) Placing the client in a supine position with legs elevated is not a priority action when a transfusion reaction is suspected. The priority is to stop the transfusion and assess the client's vital signs and symptoms.
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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 C
Explanation
A) Incorrect: Slowing down the transfusion rate is not the appropriate action in this scenario. The client is experiencing signs of an allergic reaction, and the nurse must act promptly to address the situation.
B) Incorrect: Elevating the client's feet and lowering the head (Trendelenburg position) is not indicated for an allergic reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.
C) Correct: The nurse should immediately discontinue the transfusion and initiate the infusion of normal saline to maintain the client's intravascular volume. Discontinuing the blood transfusion helps prevent further exposure to the allergen (if an allergic reaction is confirmed) and addresses fluid volume needs.
D) Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic reaction, it is not the immediate action. The nurse should first discontinue the transfusion and infuse normal saline as stated in option C.
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