A nurse is monitoring a client who is receiving a blood transfusion. After 15 minutes of starting the transfusion, the client develops hives, itching, and facial swelling. What is the nurse's immediate action?
Slow down the transfusion rate.
Elevate the client's feet and lower the head.
Discontinue the transfusion and infuse normal saline.
Administer an antihistamine as prescribed.
The Correct Answer is C
A) Incorrect: Slowing down the transfusion rate is not the appropriate action in this scenario. The client is experiencing signs of an allergic reaction, and the nurse must act promptly to address the situation.
B) Incorrect: Elevating the client's feet and lowering the head (Trendelenburg position) is not indicated for an allergic reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.
C) Correct: The nurse should immediately discontinue the transfusion and initiate the infusion of normal saline to maintain the client's intravascular volume. Discontinuing the blood transfusion helps prevent further exposure to the allergen (if an allergic reaction is confirmed) and addresses fluid volume needs.
D) Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic reaction, it is not the immediate action. The nurse should first discontinue the transfusion and infuse normal saline as stated in option C.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct: The client's symptoms of respiratory distress and chest pain indicate a potential transfusion-related acute lung injury (TRALI), a severe transfusion reaction. The nurse's priority intervention is to administer oxygen via a non-rebreather mask to improve oxygenation.
B) Incorrect: Discontinuing the blood transfusion immediately is necessary in suspected cases of TRALI, but it is not the priority intervention. First, the nurse should provide immediate respiratory support by administering oxygen.
C) Incorrect: Elevating the client's feet and lowering the head (Trendelenburg position) is not indicated for TRALI. It may be used for clients in shock, but the priority is to manage the client's respiratory distress and chest pain.
D) Incorrect: Administering diuretics is not the priority intervention for TRALI. TRALI is caused by a reaction to plasma components, not fluid overload, and diuretics may not address the underlying cause.
Correct Answer is C
Explanation
A) Incorrect: Warming the blood product in a microwave oven is not an appropriate action and could lead to hemolysis of the blood components. Blood should be warmed using an approved blood warmer designed for this purpose.
B) Incorrect: Administering a discolored blood product or one containing clots is unsafe and could cause harm to the client. The nurse should not proceed with the administration and should take appropriate actions.
C) Correct: If the nurse discovers that the blood product is discolored or contains clots, the nurse should discard the blood product appropriately and notify the blood bank immediately. This will ensure that the client receives a safe and suitable blood product for the transfusion.
D) Incorrect: Filtering the blood product through a standard IV filter is not sufficient to remove any clots present in the blood product. Using a blood product that appears abnormal could lead to adverse reactions in the client, so it is essential to obtain a replacement from the blood bank.
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