A nurse is caring for a client who experiences an acute hemolytic transfusion reaction. What intervention should the nurse anticipate implementing?

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. 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.