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?

Discontinue the blood transfusion immediately.

Administer an antihistamine to manage the current reaction.

Notify the healthcare provider for further evaluation.

Obtain a sample for repeat crossmatching.

Answer and Explanation

The Correct Answer is D

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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Correct Answer is B

Explanation

A) Incorrect: Placing the client in a supine position with legs elevated is not appropriate in this situation. The client is showing signs of a potential severe allergic reaction (anaphylaxis) or a transfusion-related acute lung injury (TRALI), and the nurse should prioritize interventions accordingly.

B) Correct: Administering oxygen via a non-rebreather mask is the appropriate immediate action for a client experiencing respiratory distress and muffled heart sounds. This intervention helps improve oxygenation and respiratory function.

C) Incorrect: Checking the client's temperature and administering antipyretics is not indicated as the client's symptoms are not consistent with a fever. The focus should be on respiratory and cardiovascular support.

D) Incorrect: Stopping the blood transfusion is essential, but it is not the immediate action in this situation. The nurse's priority is to address the client's respiratory distress and ensure adequate oxygenation by administering oxygen, as stated in option B. Once the client is stable, the nurse should then notify the healthcare provider about the situation.

Questions

A. Administer a bolus of normal saline. B. Elevate the client's feet and lower the head. C. Check the client's hemoglobin and hematocrit levels. D. Notify the healthcare provider for further evaluation.

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

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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?

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