A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?

Administer the blood transfusion slowly to observe for any reactions.

Discontinue the blood transfusion immediately and return the blood to the blood bank.

Increase the infusion rate to flush out the incompatibility.

Mix the incompatible blood with normal saline before transfusion.

Answer and Explanation

The Correct Answer is B

A) Incorrect: Administering the blood transfusion when agglutination and incompatibility are detected is unsafe and may lead to severe transfusion reactions. The nurse should not proceed with the transfusion.

B) Correct: In the presence of agglutination and incompatibility between the donor's red blood cells and the client's plasma, the nurse must discontinue the blood transfusion immediately and return the blood to the blood bank. This ensures the client's safety and prevents further adverse reactions.

C) Incorrect: Increasing the infusion rate will not resolve the incompatibility issue and may worsen the client's condition. The nurse should stop the transfusion promptly.

D) Incorrect: Mixing the incompatible blood with normal saline will not resolve the incompatibility issue and is not a safe practice. The nurse should not proceed with the transfusion and should return the blood to the blood bank.

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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. Pre-medicate the client with antihistamines before the transfusion. B. Administer the blood transfusion rapidly to minimize exposure. C. Ensure that the blood product is warmed before administration. D. Monitor the client's vital signs frequently during the transfusion.

Correct Answer is A

Explanation

A) Correct: Pre-medicating the client with antihistamines before the transfusion can help prevent or minimize allergic transfusion reactions in clients with a history of severe allergies. Antihistamines block histamine release, reducing the risk of allergic symptoms.

B) Incorrect: Administering the blood transfusion rapidly is not a preventive measure for allergic transfusion reactions. In fact, rapid administration may increase the risk of adverse reactions.

C) Incorrect: Warming the blood product before administration is important to prevent hypothermia but is not directly related to preventing allergic transfusion reactions.

D) Incorrect: Monitoring the client's vital signs during the transfusion is a standard practice, but it is not the primary intervention for preventing allergic transfusion reactions. Pre-medication with antihistamines is a more targeted approach.

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A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?

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 client has a history of severe allergic reactions and is scheduled to receive a blood transfusion. What intervention should the nurse implement to prevent an allergic transfusion reaction in this client?

Correct Answer is A

Explanation

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A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?