A nurse is caring for a client who is receiving a unit of PRBCs. The nurse suspects the client is experiencing a transfusion reaction. Which of the following actions should the nurse take first?

Infuse 0.9% sodium chloride.

Stop the transfusion.

Return the unit of blood to the blood bank

Obtain a blood sample from the client.

Answer and Explanation

The Correct Answer is B

A.   While administering 0.9% sodium chloride is an important step to maintain venous access and to help dilute any blood that might still be in the tubing, it is not the first action to take if a transfusion reaction is suspected. This step should occur after the transfusion is stopped and the patient’s safety is ensured.
B.   The immediate priority when a transfusion reaction is suspected is to stop the transfusion immediately. This action helps to prevent further exposure to the potentially harmful blood product and mitigates the risk of worsening the reaction. Stopping the transfusion also allows for prompt medical assessment and intervention.
C.   Returning the unit of blood to the blood bank is important for investigation and to determine the cause of the reaction, but it should be done after stopping the transfusion and ensuring the client’s safety. The blood bank may require the returned unit to confirm any issues with the blood product.

D.   Obtaining a blood sample from the client is crucial for diagnostic purposes and to identify the cause of the reaction, but this should be done after the transfusion has been stopped. The sample may help in diagnosing the type of reaction or in managing it, but it does not address the immediate safety concerns.

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Correct Answer is B

Explanation

A. Deep breathing exercises should be performed regularly, regardless of the level of pain. The exercises are crucial for preventing lung complications, and pain management should be addressed so that the client can perform these exercises effectively.
B. This statement reflects a proper understanding of the importance of regular deep breathing exercises. Performing these exercises every hour while awake helps to keep the alveoli open and reduces the risk of atelectasis and pneumonia. Consistent practice is essential for maximizing lung expansion and preventing complications.
C. Coughing exercises should be performed regularly, not just when experiencing shortness of breath. Coughing helps to clear secretions from the airways and prevent their accumulation, which can lead to respiratory infections and other complications.
D. Avoiding deep breathing exercises is not advisable. While there may be some discomfort, deep breathing is essential for lung health post-operatively. The exercises help prevent complications such as atelectasis.

A. 0.9% sodium chloride (NS) B. 0.45% sodium chloride (1/2 NS) C. Dextrose 5% in Lactated Ringer's (DSLR) D. Lactated Ringer's (LR)

Correct Answer is B

Explanation

A. 0.9% sodium chloride, also known as Normal Saline, is an isotonic solution. It has the same concentration of solutes as blood plasma, which means it does not change the cell's fluid volume but rather maintains it. It is not considered hypotonic.

B. 0.45% sodium chloride, commonly known as Half Normal Saline, is a hypotonic solution. It has a lower concentration of sodium chloride compared to the normal saline and is used to provide hydration and to help correct electrolyte imbalances by allowing water to move into the cells.
C. Dextrose 5% in Lactated Ringer's is not a hypotonic solution. It is actually a type of hypertonic solution. Initially, dextrose 5% is isotonic, but once the dextrose is metabolized, the solution becomes hypotonic due to the electrolyte content of Lactated Ringer’s. However, the classification is generally based on the solution before metabolism, and it is not commonly used as a hypotonic solution.
D. Lactated Ringer's solution is an isotonic solution. It contains electrolytes in concentrations similar to those found in the body's plasma, and it is used to restore fluids and electrolytes. It does not have a hypotonic effect on cells.

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A nurse is caring for a client who is receiving a unit of PRBCs. The nurse suspects the client is experiencing a transfusion reaction. Which of the following actions should the nurse take first?

Nursing Test Bank

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