A client who received a blood transfusion 2 hours ago is now experiencing symptoms of a transfusion reaction, including fever, chills, and shortness of breath. What is the nurse's priority action?
Notify the healthcare provider immediately.
Administer antipyretics to lower the client's fever.
Prepare to administer a diuretic to manage fluid overload.
Discontinue the blood transfusion immediately.
None
None
The Correct Answer is D
A. Notifying the healthcare provider is important, but the immediate priority is to stop the transfusion to prevent further exposure to the potential offending blood product.
B. Administering antipyretics addresses fever but does not stop the transfusion, so it does not prevent worsening of a potentially serious reaction.
C. Preparing a diuretic may be appropriate for fluid overload, but the symptoms described (fever, chills, shortness of breath) suggest a transfusion reaction, not just fluid overload. Immediate action is needed to prevent harm.
D. Discontinuing the blood transfusion immediately is the priority action because it prevents additional exposure to the blood product causing the reaction and is the first step in transfusion reaction protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect: Confirming the client's identity and blood type with the client's family member is not a reliable method for ensuring patient safety during a blood transfusion. The nurse should directly 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.
B) Correct: Obtaining informed consent from the client is a crucial step before initiating a blood transfusion. The nurse must ensure the client understands the risks and benefits of the transfusion and has willingly provided consent. A signed consent form is the formal documentation of this process.
C) Incorrect: Warming blood in a microwave oven is not an appropriate method for preventing hypothermia and can lead to hemolysis of the blood components. Blood should be warmed using an approved blood warmer designed for this purpose.
D) Incorrect: Administering a rapid bolus of normal saline is unnecessary and could lead to fluid overload in the client. The nurse should administer normal saline or another appropriate IV fluid at the prescribed rate if the client requires hydration before or after the transfusion, but not as a priming method.
Correct Answer is ["A","B","D"]
Explanation
A) Obtaining the client's informed consent is a critical step before any medical procedure, including blood transfusions. This ensures the client understands the risks and benefits of the transfusion and gives their consent willingly.
B) Confirming the client's blood type and Rh factor with the blood bank is essential to prevent transfusion reactions. Mismatching blood types can lead to severe transfusion reactions and is a crucial step in the transfusion process.
C) Administering pre-medication to prevent transfusion reactions is not a standard practice. However, the nurse should assess the client for any risk factors or history of previous transfusion reactions to take appropriate precautions.
D) Assessing the client's blood pressure and heart rate is an important part of the overall assessment before the blood transfusion.
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