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 B
Explanation
A) Incorrect: Confirming the client's identity and blood type with the client's family member is not a reliable method for ensuring patient safety during a blood transfusion. The nurse should directly verify the client's identity and blood type with two unique identifiers, such as asking the client to state their full name and date of birth and comparing it to their identification band.
B) Correct: Obtaining informed consent from the client is a crucial step before initiating a blood transfusion. The nurse must ensure the client understands the risks and benefits of the transfusion and has willingly provided consent. A signed consent form is the formal documentation of this process.
C) Incorrect: Warming blood in a microwave oven is not an appropriate method for preventing hypothermia and can lead to hemolysis of the blood components. Blood should be warmed using an approved blood warmer designed for this purpose.
D) Incorrect: Administering a rapid bolus of normal saline is unnecessary and could lead to fluid overload in the client. The nurse should administer normal saline or another appropriate IV fluid at the prescribed rate if the client requires hydration before or after the transfusion, but not as a priming method.
Correct Answer is A
Explanation
A) Correct: Fresh Frozen Plasma (FFP) contains various clotting factors and is used to treat clotting factor deficiencies such as those found in coagulopathies or liver disease.
B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction, not clotting factor deficiencies.
C) Incorrect: Cryoprecipitate is derived from FFP and contains concentrated fibrinogen and other clotting factors. It is used for specific clotting factor deficiencies but is not the primary treatment for clotting factor deficiencies in general.
D) Incorrect: Packed Red Blood Cells (PRBCs) are used to treat anemia and improve oxygenation but do not address clotting factor deficiencies.
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