A client undergoing a blood transfusion reports sudden onset urticaria, pruritus, and flushing.
What type of transfusion reaction is the client likely experiencing based on these symptoms?

Choice A rationale:

Verify the patient's identification.

Rationale: Ensuring the correct patient is receiving the blood transfusion is a critical safety step.

Verifying the patient's identification helps prevent transfusion errors and ensures that the right blood product is administered to the right patient.

Choice B rationale:

Obtain informed consent.

Rationale: Obtaining informed consent is a necessary step before any medical procedure, including blood transfusions.

It ensures that the patient understands the risks, benefits, and alternatives to the transfusion and has the opportunity to ask questions and make an informed decision.

Choice E rationale:

Document the procedure accurately.

Rationale: Accurate documentation is essential for maintaining a complete record of the transfusion process.

It includes documenting the patient's identification, vital signs, the type and volume of blood product administered, any adverse reactions, and the patient's response to the transfusion.

This documentation serves as a legal and clinical record of the procedure.

Choice C rationale:

Monitor vital signs during the transfusion.

Rationale: While monitoring vital signs is important during a blood transfusion, it is not a responsibility before initiating the transfusion.

Vital sign monitoring occurs during the transfusion to detect any immediate adverse reactions or transfusion-related complications.

Choice D rationale:

Prepare the patient for an exchange transfusion.

Rationale: Preparing a patient for an exchange transfusion is not a nursing responsibility before initiating a routine blood transfusion.

Exchange transfusions are typically used for specific medical conditions, such as hemolytic disease of the newborn or sickle cell disease, and involve the removal and replacement of a large volume of blood.

Standard blood transfusions do not require this preparation.

For , fresh frozen plasma (FFP) is the most suitable blood product for increasing fibrinogen levels in a patient with hemophilia A.

For , the nursing responsibilities before initiating a blood transfusion include verifying the patient's identification, obtaining informed consent, and documenting the procedure accurately.

Monitoring vital signs is important but occurs during the transfusion, and preparing the patient for an exchange transfusion is not relevant to routine blood transfusions.

"I'll stay with the patient for the entire transfusion."

Choice A rationale:

Staying with the patient for the entire transfusion is a crucial safety measure.

The nurse must monitor the patient for any signs of a transfusion reaction, such as fever, chills, rash, shortness of breath, or changes in vital signs.

Immediate intervention may be required if a reaction occurs.

Choice B rationale:

Adding medications to the blood bag is not within the nurse's scope of practice and should not be done without a specific physician's order.

Medications should be administered separately through a different IV line, if necessary, and only as ordered.

Choice C rationale:

Administering the transfusion at a rate of 4 mL/min is not a standard practice.

The rate of transfusion is determined by the physician's order and the patient's specific needs.

It is not a fixed rate and should be adjusted as needed.

Choice D rationale:

Using any available intravenous line for the transfusion may not be appropriate, especially if the line is already in use for other medications or fluids.

The nurse should select a dedicated line for the transfusion to minimize the risk of contamination or complications.