A nurse is assessing a client who just received a blood transfusion. The client complains of back pain, fever, and chills. What action should the nurse take first?

Notify the healthcare provider immediately.

Administer acetaminophen to reduce the fever.

Stop the transfusion and disconnect the IV tubing.

Infuse normal saline to maintain the client's hydration.

Answer and Explanation

The Correct Answer is C

A. Notifying the healthcare provider is important but should be done after stopping the transfusion to prevent further reaction.
B. Administering acetaminophen does not address the underlying cause of the reaction and should not be the priority.
C. Stopping the transfusion and disconnecting the IV tubing is the first priority to prevent further exposure to the incompatible blood product, which could lead to a life-threatening hemolytic reaction.
D. Infusing normal saline is appropriate to maintain hydration, but it should be done after stopping the transfusion.

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Correct Answer is C

Explanation

A) Incorrect: Administering epinephrine is not the appropriate intervention for an allergic transfusion reaction characterized by urticaria and itching. Epinephrine is used to treat anaphylactic reactions.

B) Incorrect: Stopping the transfusion and disconnecting the IV tubing is appropriate in the event of an allergic transfusion reaction, but it should not be the first action. The nurse should first slow down or stop the transfusion if mild symptoms are present and notify the healthcare provider for further instructions.

C) Correct: Slowing down the transfusion rate may be appropriate for mild allergic reactions to reduce symptoms. However, if the reaction worsens, the nurse should stop the transfusion immediately.

D) Incorrect: Obtaining a blood sample for repeat crossmatching is not indicated in an allergic transfusion reaction. Allergic reactions are related to hypersensitivity to plasma proteins and do not involve compatibility issues between red blood cells and plasma.

Questions

A. Iron-deficiency anemia B. Chronic kidney disease C. Hemolytic anemia D. Hypertension

Correct Answer is C

Explanation

A) Incorrect: Iron-deficiency anemia is not a contraindication for a blood transfusion. In fact, it is one of the common indications for transfusion in clients with severe anemia.

B) Incorrect: Chronic kidney disease is not a contraindication for a blood transfusion. Transfusions may be necessary for clients with chronic kidney disease who develop anemia due to decreased erythropoietin production.

C) Correct: Hemolytic anemia is a contraindication for a blood transfusion. This condition involves the destruction of red blood cells, and a transfusion with incompatible blood can worsen the hemolysis and lead to a severe transfusion reaction.

D) Incorrect: Hypertension is not a contraindication for a blood transfusion. While the nurse should monitor blood pressure during the transfusion, hypertension alone does not preclude the need for a transfusion in a client with other indications for blood products.

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A nurse is assessing a client who just received a blood transfusion. The client complains of back pain, fever, and chills. What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who develops urticaria (hives) and itching during a blood transfusion. The nurse suspects an allergic transfusion reaction. What is the appropriate nursing action?

Correct Answer is C

Explanation

A nurse is assessing a client's history before a blood transfusion. Which condition should the nurse identify as a contraindication for transfusion?

Correct Answer is C

Explanation

A nurse is preparing to crossmatch blood for a client who requires a blood transfusion. Which blood component is involved in the crossmatching process?

A nurse is preparing to administer a blood transfusion to a client. Which action should the nurse take before initiating the transfusion?

A nurse is caring for a client who is about to receive a blood transfusion. What information should the nurse provide to the client to prevent an allergic transfusion reaction?

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 preparing to crossmatch blood for a client with blood type O-positive(O+). Which blood type can safely receive blood from this client?

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?

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?

A client has a history of severe allergic reactions and is scheduled to receive a blood transfusion. What intervention should the nurse implement to prevent an allergic transfusion reaction in this client?