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.

Answer and Explanation

The Correct Answer is A

A: Notifying the healthcare provider is an important step, but it is not the immediate priority. The nurse's first action should be to address the adverse reaction to prevent further harm to the client.

B: While administering antipyretics may help lower the client's fever, it does not address the underlying cause of the symptoms, which is the transfusion reaction. The priority is to stop the reaction from progressing.

C: Preparing to administer a diuretic would be appropriate if fluid overload was the primary concern. However, in the case of a transfusion reaction, the priority is to stop the transfusion to halt the reaction.

D: Discontinuing the blood transfusion immediately is the priority action because it stops the exposure to the blood product that is causing the reaction. Once the transfusion is stopped, further interventions can be assessed and implemented.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A) Incorrect: Administering antipyretics to reduce fever is not the appropriate intervention for an acute hemolytic transfusion reaction. This type of reaction involves the destruction of red blood cells, not an elevation in body temperature.

B) Incorrect: Preparing to administer a diuretic is not the appropriate intervention for an acute hemolytic transfusion reaction. Fluid overload is not a typical feature of this type of reaction.

C) Correct: Monitoring the client's vital signs frequently is a crucial intervention for an acute hemolytic transfusion reaction. This type of reaction can cause rapid onset of severe symptoms, including fever, chills, hypotension, tachycardia, and potential shock.

D) Incorrect: Administering epinephrine is not the appropriate intervention for an acute hemolytic transfusion reaction. Epinephrine is used to treat anaphylactic reactions, not hemolytic reactions.

A. Fresh Frozen Plasma (FFP) B. Platelets C. Cryoprecipitate D. Packed Red Blood Cells (PRBCs)

Correct Answer is A

Explanation

A) Correct: Fresh Frozen Plasma (FFP) contains various clotting factors and is used to manage clotting factor deficiencies, including those related to liver disease.

B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction but do not primarily address clotting factor deficiencies caused by liver disease.

C) Incorrect: Cryoprecipitate is derived from FFP and contains concentrated fibrinogen and other clotting factors. It may be used in some cases of liver disease, but FFP is the more common choice for managing these conditions.

D) Incorrect: Packed Red Blood Cells (PRBCs) are used to improve oxygenation in anemic clients and are not the primary treatment for clotting factor deficiencies related to liver disease.

Questions

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who experiences an acute hemolytic transfusion reaction. What intervention should the nurse anticipate implementing?

Correct Answer is C

Explanation

A client with severe liver disease has a decreased ability to synthesize clotting factors. Which blood product should the nurse anticipate being prescribed to manage the client's condition?

Correct Answer is A

Explanation

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?

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?

A client received a blood transfusion 2 hours ago. The nurse is assessing for signs of a delayed transfusion reaction. Which assessment finding should the nurse report to the healthcare provider?

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 preparing to administer a platelet transfusion to a client with severe thrombocytopenia. The nurse should:

A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?

A nurse is preparing to administer a blood transfusion to a client. What is the nurse's priority action to prevent a potential complication related to blood compatibility?

A nurse is caring for a client with severe hypoalbuminemia. Which blood product should the nurse anticipate being prescribed to address the client's condition?