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

A) Raising the head of the client's bed and administering oxygen is the immediate action to improve oxygenation and relieve respiratory distress in a client experiencing potential pulmonary edema, as evidenced by the pink, frothy sputum.

B) Obtaining a sputum sample for culture and sensitivity testing may be important to assess for infection, but it is not the nurse's immediate action in response to a severe transfusion reaction.

C) Administering a diuretic may help with pulmonary congestion, but it is not the nurse's immediate action in response to a severe transfusion reaction. The priority is to improve oxygenation.

D) Discontinuing the blood transfusion and removing the IV catheter is important, but the immediate action to address the client's respiratory distress is to raise the head of the bed and administer oxygen. Stopping the transfusion can follow after the client's respiratory status stabilizes.

Questions

A) Incorrect: Fresh Frozen Plasma (FFP) is not the appropriate blood product for immediate volume replacement. It contains clotting factors and is used to manage bleeding disorders.

B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction and do not provide volume replacement.

C) Correct: Packed Red Blood Cells (PRBCs) contain red blood cells and are used for volume replacement in clients with acute blood loss or anemia.

D) Incorrect: Albumin is used for volume expansion in cases of hypoalbuminemia and fluid resuscitation in certain situations, but PRBCs are more effective for rapid volume replacement.