A nurse is monitoring a client who just received a blood transfusion. The client suddenly develops dyspnea, tachycardia, and chest pain. What is the nurse's priority action?
Elevate the head of the bed to promote lung expansion.
Administer diuretics to manage fluid overload.
Stop the transfusion immediately and notify the healthcare provider.
Document the client's symptoms and continue the transfusion at a slower rate.
The Correct Answer is C
A) Incorrect: Elevating the head of the bed may help promote lung expansion, but it is not the nurse's priority action when the client is experiencing severe symptoms like dyspnea, tachycardia, and chest pain during a transfusion.
B) Incorrect: Administering diuretics is not the appropriate action for the client's symptoms, which suggest a possible transfusion-related acute lung injury (TRALI) or acute hemolytic transfusion reaction. Diuretics will not address the underlying cause.
C) Correct: The client's symptoms of dyspnea, tachycardia, and chest pain indicate a potential severe transfusion reaction. The nurse's priority action is to stop the transfusion immediately and notify the healthcare provider for further evaluation and intervention.
D) Incorrect: Continuing the transfusion at a slower rate is not appropriate when the client is experiencing severe symptoms. The nurse should first stop the transfusion and then notify the healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect: Increasing the rate of the blood transfusion is not the appropriate action when the client is experiencing respiratory distress. Rapid transfusion may exacerbate the TRALI and lead to further complications.
B) Correct: Administering oxygen via a nasal cannula or face mask is a priority action for a client experiencing respiratory distress. Providing supplemental oxygen can help improve oxygenation and prevent further complications.
C) Incorrect: Placing the client in a supine position with legs elevated is not the appropriate action for a client with respiratory distress. This position may worsen the client's breathing difficulties.
D) Incorrect: Restarting the transfusion with a different blood product is not indicated in the presence of suspected TRALI. The nurse's priority is to manage the client's respiratory distress and discontinue the transfusion if necessary.
Correct Answer is A
Explanation
A) Correct: Fresh Frozen Plasma (FFP) contains various clotting factors and is used to manage clotting factor deficiencies, including those related to liver disease.
B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction but do not primarily address clotting factor deficiencies caused by liver disease.
C) Incorrect: Cryoprecipitate is derived from FFP and contains concentrated fibrinogen and other clotting factors. It may be used in some cases of liver disease, but FFP is the more common choice for managing these conditions.
D) Incorrect: Packed Red Blood Cells (PRBCs) are used to improve oxygenation in anemic clients and are not the primary treatment for clotting factor deficiencies related to liver disease.
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