A client is receiving a blood transfusion, and the nurse suspects a transfusion-related acute lung injury (TRALI) due to sudden respiratory distress. What action should the nurse take to prevent further complications?

Increase the rate of the blood transfusion to complete it quickly.

Administer oxygen via a nasal cannula or face mask.

Place the client in a supine position with legs elevated.

Restart the transfusion with a different blood product.

Answer and Explanation

The Correct Answer is B

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.

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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. Fresh Frozen Plasma (FFP) B. Platelets C. Cryoprecipitate D. Packed Red Blood Cells (PRBCs)

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.

Questions

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A client is receiving a blood transfusion, and the nurse suspects a transfusion-related acute lung injury (TRALI) due to sudden respiratory distress. What action should the nurse take to prevent further complications?

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

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Correct Answer is A

Explanation

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