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 A
Explanation
A) Raising the head of the client's bed and administering oxygen is the immediate action to improve oxygenation and relieve respiratory distress in a client experiencing potential pulmonary edema, as evidenced by the pink, frothy sputum.
B) Obtaining a sputum sample for culture and sensitivity testing may be important to assess for infection, but it is not the nurse's immediate action in response to a severe transfusion reaction.
C) Administering a diuretic may help with pulmonary congestion, but it is not the nurse's immediate action in response to a severe transfusion reaction. The priority is to improve oxygenation.
D) Discontinuing the blood transfusion and removing the IV catheter is important, but the immediate action to address the client's respiratory distress is to raise the head of the bed and administer oxygen. Stopping the transfusion can follow after the client's respiratory status stabilizes.
Questions
Correct Answer is C
Explanation
A) Incorrect: Elevating the head of the bed may help promote lung expansion, but it is not the nurse's priority action when the client is experiencing severe symptoms like dyspnea, tachycardia, and chest pain during a transfusion.
B) Incorrect: Administering diuretics is not the appropriate action for the client's symptoms, which suggest a possible transfusion-related acute lung injury (TRALI) or acute hemolytic transfusion reaction. Diuretics will not address the underlying cause.
C) Correct: The client's symptoms of dyspnea, tachycardia, and chest pain indicate a potential severe transfusion reaction. The nurse's priority action is to stop the transfusion immediately and notify the healthcare provider for further evaluation and intervention.
D) Incorrect: Continuing the transfusion at a slower rate is not appropriate when the client is experiencing severe symptoms. The nurse should first stop the transfusion and then notify the healthcare provider.
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