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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect: Fresh Frozen Plasma (FFP) contains clotting factors and is used to treat bleeding disorders, but it is not primarily responsible for promoting clot formation and controlling bleeding.
B) Correct: Platelets are responsible for promoting clot formation and controlling bleeding. They play a crucial role in hemostasis and are used to treat thrombocytopenia and platelet dysfunction.
C) Incorrect: Packed Red Blood Cells (PRBCs) primarily carry oxygen and are used to treat anemia and improve oxygenation, but they do not have a direct role in clot formation or controlling bleeding.
D) Incorrect: Albumin is a protein used to expand intravascular volume, especially in cases of hypoalbuminemia, but it does not have a significant role in clot formation or controlling bleeding.
Correct Answer is A
Explanation
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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