A nurse is caring for a client who is about to receive a blood transfusion. What information should the nurse provide to the client to prevent an allergic transfusion reaction?
"You may experience a mild fever and chills during the transfusion, which is normal."
"If you develop any itching, rash, or facial swelling, please notify me immediately."
"Expect a brief period of increased heart rate after the transfusion is completed."
"It is common to have lower back pain after receiving a blood transfusion."
The Correct Answer is B
A) Incorrect: Fever and chills during a blood transfusion may be signs of a febrile transfusion reaction, not an allergic reaction. The nurse should provide information specific to preventing allergic reactions.
B) Correct: Itching, rash, and facial swelling are common signs of an allergic transfusion reaction. The nurse should instruct the client to notify the healthcare provider immediately if they experience these symptoms.
C) Incorrect: A brief period of increased heart rate after the transfusion may be normal, but it is not specific to preventing an allergic transfusion reaction. The nurse should focus on providing information about allergic reaction symptoms.
D) Incorrect: Lower back pain is not typically associated with allergic transfusion reactions. The nurse should provide information about symptoms that indicate an allergic reaction, such as itching, rash, and facial swelling.
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Related Questions
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.
Correct Answer is A
Explanation
A) Correct: Red blood cells are the main blood component involved in the crossmatching process. Crossmatching ensures compatibility between the donor's red blood cells and the recipient's plasma, preventing adverse reactions during the transfusion.
B) Incorrect: White blood cells are not part of the crossmatching process. They play a role in the immune response but are not specifically assessed during crossmatching.
C) Incorrect: Platelets are not directly involved in the crossmatching process. Crossmatching primarily focuses on red blood cell compatibility.
D) Incorrect: Plasma is not directly involved in the crossmatching process. The focus is on ensuring compatibility between red blood cells and the recipient's plasma.
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