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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hyperventilation can lead to dizziness and lightheadedness, and it's not a recommended method for preventing atelectasis.
B. This statement indicates understanding of the importance of deep breathing exercises in preventing atelectasis.
C. This statement shows a misunderstanding of atelectasis. Anyone can develop atelectasis, especially after surgery.
D. This statement is incorrect, but it focuses on treatment rather than prevention.
Correct Answer is B
Explanation
A. Abdominal pain is not a direct manifestation of respiratory acidosis. However, it may be associated with other conditions or complications but is not a primary indicator of respiratory acidosis.
B. Lethargy or drowsiness is a common symptom of respiratory acidosis. The increased CO₂ levels lead to an acidic environment that can affect brain function, resulting in decreased alertness, confusion, or drowsiness.
C. Numbness or tingling of the fingers is more commonly associated with respiratory alkalosis, which is characterized by a decreased level of CO₂ and increased blood pH. This condition can cause peripheral numbness and tingling due to altered blood pH affecting nerve function.
D. Dry skin is not a direct manifestation of respiratory acidosis. While it might be a sign of dehydration or other systemic issues, it is not specifically linked to respiratory acidosis.
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