A nurse is monitoring a client during a blood transfusion. The client suddenly develops hives, itching, and facial swelling. What is the nurse's immediate action?

Stop the transfusion immediately and notify the healthcare provider.

Administer an antihistamine to manage the allergic reaction.

Slow down the transfusion rate to observe for further reactions.

Place the client in a supine position with legs elevated.

Answer and Explanation

The Correct Answer is A

A) Correct: The client's symptoms of hives, itching, and facial swelling indicate a potential allergic transfusion reaction (urticarial reaction). The nurse's immediate action is to stop the transfusion immediately and notify the healthcare provider for further evaluation and intervention.

B) Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic transfusion reaction, it is not the immediate action. The nurse should first stop the transfusion and notify the healthcare provider.

C) Incorrect: Slowing down the transfusion rate is not appropriate in the presence of an allergic transfusion reaction. The nurse should stop the transfusion immediately.

D) Incorrect: Placing the client in a supine position with legs elevated is not indicated for an allergic transfusion reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.

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Correct Answer is ["A","B","D"]

Explanation

A) Obtaining the client's informed consent is a critical step before any medical procedure, including blood transfusions. This ensures the client understands the risks and benefits of the transfusion and gives their consent willingly.

B) Confirming the client's blood type and Rh factor with the blood bank is essential to prevent transfusion reactions. Mismatching blood types can lead to severe transfusion reactions and is a crucial step in the transfusion process.

C) Administering pre-medication to prevent transfusion reactions is not a standard practice. However, the nurse should assess the client for any risk factors or history of previous transfusion reactions to take appropriate precautions.

D) Assessing the client's blood pressure and heart rate is an important part of the overall assessment before the blood transfusion.

A. Client reports mild headache. B. Client has slightly elevated temperature. C. Client's skin appears pale and cool to touch. D. Client experiences generalized muscle weakness.

Correct Answer is B

Explanation

A) Incorrect: A mild headache is a common and expected side effect of a blood transfusion and may not require immediate reporting to the healthcare provider.

B) Correct: A slightly elevated temperature in a client who received a blood transfusion 2 hours ago could indicate a delayed transfusion reaction. The nurse should report this finding to the healthcare provider for further evaluation.

C) Incorrect: Pale and cool skin may be an expected finding in a client who received a blood transfusion, especially if they experienced a rapid transfusion or had a reaction. However, it is not the priority finding to report.

D) Incorrect: Generalized muscle weakness may occur for various reasons and may not be directly related to a delayed transfusion reaction. The nurse should prioritize reporting the slightly elevated temperature.

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A nurse is monitoring a client during a blood transfusion. The client suddenly develops hives, itching, and facial swelling. What is the nurse's immediate action?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a unit of packed red blood cells (PRBCs) to a client with severe anemia. Before starting the blood transfusion, the nurse should:

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is B

Explanation

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