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."

Answer and Explanation

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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Correct Answer is A

Explanation

A) Correct: The nurse should verify the client's identity and blood type with two unique identifiers, such as asking the client to state their full name and date of birth and comparing it to their identification band. This step ensures that the correct blood product is administered to the right client, promoting safety.

B) Incorrect: Confirming the expiration date of the blood product is important but not the first step in ensuring client safety during a blood transfusion. The nurse should first verify the client's identity and blood type.

C) Incorrect: Assessing the client's vital signs is essential, but it is not the first action to be taken. Verifying the client's identity and blood type is the priority before starting the transfusion.

D) Incorrect: Obtaining informed consent from the client is crucial but not the first action to be taken. The nurse should first verify the client's identity and blood type before seeking consent for the transfusion.

A. Administer epinephrine immediately. B. Stop the transfusion and disconnect the IV tubing. C. Slow down the transfusion rate. D. Obtain a blood sample for repeat crossmatching.

Correct Answer is C

Explanation

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.

Questions

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to initiate a blood transfusion for a client. Which action should the nurse take first to ensure client safety?

Correct Answer is A

Explanation

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?

Correct Answer is C

Explanation

A nurse is preparing to administer a blood transfusion to a client. What is the nurse's priority action to prevent a potential complication related to blood compatibility?

A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?

A client receiving a blood transfusion develops sudden chest pain, dyspnea, and a productive cough with pink, frothy sputum. The nurse suspects a severe transfusion reaction. What is the nurse's immediate action?

A client expresses anxiety and fear about receiving a blood transfusion. What action should the nurse take to address the client's concerns?

A nurse is preparing to administer a blood transfusion to a client. Which vital sign alteration should the nurse report to the healthcare provider before initiating the transfusion?

A nurse is assessing a client who just received a blood transfusion. The client complains of back pain, fever, and chills. What action should the nurse take first?

A client receiving a blood transfusion suddenly develops chills, fever, and lower back pain. The nurse suspects a transfusion reaction. What is the nurse's priority action?

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?