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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A) Incorrect: A slight increase in blood pressure is not a significant vital sign alteration that requires immediate reporting before initiating the transfusion. It could be related to various factors, such as anxiety or pain.

B) Incorrect: A respiratory rate of 22 breaths per minute is within the normal range for an adult and does not require immediate reporting before starting the transfusion.

C) Incorrect: A decrease in heart rate from 88 to 72 beats per minute is not a critical vital sign alteration. As long as the heart rate remains within the client's baseline range, it does not need immediate reporting.

D) Correct: An elevated temperature of 38.5°C (101.3°F) may indicate a fever, which could be a sign of an infection or an adverse reaction to the transfusion. The nurse should report this vital sign alteration to the healthcare provider before proceeding with the transfusion to determine the appropriate course of action.

A. Mild itching on the client's forearms. B. Mild lower back pain that subsides. C. Blood pressure increase by 10 mmHg from baseline. D. Hemoglobin level increase by 2 g/dL after the transfusion.

Correct Answer is C

Explanation

A) Incorrect: Mild itching on the client's forearms is a common and expected side effect of a blood transfusion and may not require immediate reporting to the healthcare provider.

B) Incorrect: Mild lower back pain that subsides is not a significant finding and may not require immediate reporting to the healthcare provider.

C) Correct: An increase in blood pressure by 10 mmHg from the client's baseline may indicate a potential transfusion reaction or fluid overload. The nurse should report this finding to the healthcare provider for further evaluation.

D) Incorrect: An increase in hemoglobin level by 2 g/dL after the transfusion is a positive outcome, indicating a successful transfusion. There is no need to report this finding to the healthcare provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a blood transfusion to a client. Which vital sign alteration should the nurse report to the healthcare provider before initiating the transfusion?

Correct Answer is D

Explanation

A nurse is providing post-transfusion care to a client who just received a blood transfusion. Which assessment finding should the nurse report to the healthcare provider immediately?

Correct Answer is C

Explanation

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