A client develops respiratory distress and chest pain during a blood transfusion. The nurse suspects a transfusion-related acute lung injury (TRALI). What is the nurse's priority intervention?
Administering oxygen via a non-rebreather mask.
Discontinuing the blood transfusion immediately.
Elevating the client's feet and lowering the head.
Administering diuretics to manage fluid overload.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect: Administering antipyretics to reduce fever is not the appropriate intervention for an acute hemolytic transfusion reaction. This type of reaction involves the destruction of red blood cells, not an elevation in body temperature.
B) Incorrect: Preparing to administer a diuretic is not the appropriate intervention for an acute hemolytic transfusion reaction. Fluid overload is not a typical feature of this type of reaction.
C) Correct: Monitoring the client's vital signs frequently is a crucial intervention for an acute hemolytic transfusion reaction. This type of reaction can cause rapid onset of severe symptoms, including fever, chills, hypotension, tachycardia, and potential shock.
D) Incorrect: Administering epinephrine is not the appropriate intervention for an acute hemolytic transfusion reaction. Epinephrine is used to treat anaphylactic reactions, not hemolytic reactions.
Correct Answer is D
Explanation
A) Incorrect: Fresh Frozen Plasma (FFP) contains clotting factors and is not the primary treatment for hypoalbuminemia.
B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction, not hypoalbuminemia.
C) Incorrect: Packed Red Blood Cells (PRBCs) are primarily used to improve oxygenation in anemic clients and do not address hypoalbuminemia.
D) Correct: Albumin is the blood product of choice for addressing severe hypoalbuminemia. It is a protein that helps maintain oncotic pressure and regulates fluid balance within the blood vessels.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.