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 A

Explanation

A: Notify the healthcare provider immediately to obtain a blood transfusion order – This is the priority action because the client’s hemoglobin level of 8 g/dL, along with symptoms of hypoxia, indicates a need for urgent medical intervention. Obtaining an order for a transfusion is crucial for addressing the underlying issue of low hemoglobin and associated hypoxia.
B: Administer supplemental oxygen to the client to improve oxygenation – While this action is important, it is not the first step. The low hemoglobin indicates a need for a transfusion, and notifying the provider can lead to quicker treatment.
C: Initiating IV access with a large-bore catheter is an important step in preparation for a possible blood transfusion, but it is not the first action. The client's current symptoms must be managed promptly.
D: Ambulation may be contraindicated post-major surgery, especially when the client is symptomatic. It could exacerbate the client's condition and is not the immediate priority in this scenario.

A. Slow down the transfusion rate. B. Elevate the client's feet and lower the head. C. Discontinue the transfusion and infuse normal saline. D. Administer an antihistamine as prescribed.

Correct Answer is C

Explanation

A) Incorrect: Slowing down the transfusion rate is not the appropriate action in this scenario. The client is experiencing signs of an allergic reaction, and the nurse must act promptly to address the situation.

B) Incorrect: Elevating the client's feet and lowering the head (Trendelenburg position) is not indicated for an allergic reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.

C) Correct: The nurse should immediately discontinue the transfusion and initiate the infusion of normal saline to maintain the client's intravascular volume. Discontinuing the blood transfusion helps prevent further exposure to the allergen (if an allergic reaction is confirmed) and addresses fluid volume needs.

D) Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic reaction, it is not the immediate action. The nurse should first discontinue the transfusion and infuse normal saline as stated in option C.

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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

A nurse is caring for a client who has undergone major surgery and has a hemoglobin level of 8 g/dL. The client is experiencing symptoms of hypoxia, including tachycardia and shortness of breath. The nurse suspects the need for a blood transfusion. What action should the nurse take first?

Correct Answer is A

Explanation

A nurse is monitoring a client who is receiving a blood transfusion. After 15 minutes of starting the transfusion, the client develops hives, itching, and facial swelling. What is the nurse's immediate action?

Correct Answer is C

Explanation

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