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 A

Explanation

A. AB-positive (AB+) individuals are universal recipients for red blood cells and can safely receive blood from an O-positive (O+) donor.
B. B-negative (B-) individuals require type B or O blood but must receive Rh-negative blood to avoid incompatibility.
C. A-negative (A-) individuals require type A or O blood and must receive Rh-negative blood.
D. AB-negative (AB-) individuals require type AB, A, B, or O blood but must receive Rh-negative blood to prevent a reaction.

A. Discontinue the blood transfusion immediately. B. Administer an antihistamine to manage the current reaction. C. Notify the healthcare provider for further evaluation. D. Obtain a sample for repeat crossmatching.

Correct Answer is D

Explanation

A) Incorrect: Discontinuing the blood transfusion may be necessary if the allergic reaction is severe, but it is not the appropriate action for a mild allergic reaction. The nurse should manage the current reaction and take preventive measures for future transfusions.

B) Incorrect: Administering an antihistamine is appropriate to manage the current allergic reaction,but it may not prevent future allergic reactions. The nurse should focus on preventing allergic reactions in future transfusions.

C) Incorrect: Notifying the healthcare provider is important for appropriate management, but it may not directly prevent future allergic reactions. The nurse should implement preventive measures.

D) Correct: Obtaining a sample for repeat crossmatching is essential to identify and select blood products that are less likely to cause an allergic reaction in the client. This step can help prevent future allergic transfusion reactions and ensure safer blood product selection.

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

Correct Answer is A

Explanation

A nurse is caring for a client who experienced a mild allergic reaction during a blood transfusion. Which action should the nurse take to prevent future allergic reactions in this client?

Correct Answer is D

Explanation

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