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 D
Explanation
A. Lymphocytes are a type of white blood cell that plays a crucial role in the immune system, specifically in the response to infections and in immune regulation. They do not have a role in the transport of oxygen in the blood.
B. Neutrophils are another type of white blood cell that is essential for fighting bacterial infections. They are part of the body's immune response but do not transport oxygen.
C. Platelets are small cell fragments that are crucial for blood clotting and wound repair. They do not have a role in oxygen transport.
D. Hemoglobin is the primary molecule responsible for transporting oxygen in the blood. It is a protein found in red blood cells (erythrocytes) that binds to oxygen in the lungs and releases it in tissues throughout the body. Hemoglobin carries the majority of oxygen in the bloodstream and is essential for effective oxygen transport and delivery.
Correct Answer is C
Explanation
A. Changing the patient's head position during suctioning can increase discomfort and hypoxia.
B. This is premature. The tachycardia may be a temporary response to the suctioning procedure.
C. The increased heart rate is likely a response to the stimulation of suctioning. Stopping the procedure allows the patient to recover and reassessment can determine if further suctioning is necessary.
D. This is excessive and not necessary at this time.
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