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?

Administer epinephrine immediately.

Stop the transfusion and disconnect the IV tubing.

Slow down the transfusion rate.

Obtain a blood sample for repeat crossmatching.

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is B

Explanation

A) Incorrect: Administering a bolus of normal saline may help increase intravascular volume, but it is not the first intervention to be implemented. The nurse should first identify the cause of the client's symptoms and take appropriate actions.

B) Correct: The client's symptoms of feeling lightheaded and dizzy, along with a drop in blood pressure and an increase in heart rate, suggest orthostatic hypotension. The nurse's first intervention should be to elevate the client's feet and lower the head to improve blood flow to the brain.

C) Incorrect: Checking the client's hemoglobin and hematocrit levels is essential but may not be the first intervention in this situation. The client's symptoms indicate an immediate need to address the orthostatic hypotension.

D) Incorrect: Notifying the healthcare provider for further evaluation is important, but it may not be the first intervention. The nurse should first take immediate actions to address the client's symptoms of orthostatic hypotension.

Questions

A. Elevate the head of the bed to promote lung expansion. B. Administer diuretics to manage fluid overload. C. Stop the transfusion immediately and notify the healthcare provider. D. Document the client's symptoms and continue the transfusion at a slower rate.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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