A client is scheduled to receive a blood transfusion, but the nurse discovers that the blood product appears discolored or contains clots. What should the nurse do next?

Warm the blood product in a microwave oven to improve its condition.

Administer the blood product as usual and monitor the client closely for reactions.

Discard the blood product appropriately and notify the blood bank for a replacement.

Filter the blood product through a standard IV filter to remove any clots.

Answer and Explanation

The Correct Answer is C

A) Incorrect: Warming the blood product in a microwave oven is not an appropriate action and could lead to hemolysis of the blood components. Blood should be warmed using an approved blood warmer designed for this purpose.

B) Incorrect: Administering a discolored blood product or one containing clots is unsafe and could cause harm to the client. The nurse should not proceed with the administration and should take appropriate actions.

C) Correct: If the nurse discovers that the blood product is discolored or contains clots, the nurse should discard the blood product appropriately and notify the blood bank immediately. This will ensure that the client receives a safe and suitable blood product for the transfusion.

D) Incorrect: Filtering the blood product through a standard IV filter is not sufficient to remove any clots present in the blood product. Using a blood product that appears abnormal could lead to adverse reactions in the client, so it is essential to obtain a replacement from the blood bank.

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Correct Answer is A

Explanation

A) Raising the head of the client's bed and administering oxygen is the immediate action to improve oxygenation and relieve respiratory distress in a client experiencing potential pulmonary edema, as evidenced by the pink, frothy sputum.

B) Obtaining a sputum sample for culture and sensitivity testing may be important to assess for infection, but it is not the nurse's immediate action in response to a severe transfusion reaction.

C) Administering a diuretic may help with pulmonary congestion, but it is not the nurse's immediate action in response to a severe transfusion reaction. The priority is to improve oxygenation.

D) Discontinuing the blood transfusion and removing the IV catheter is important, but the immediate action to address the client's respiratory distress is to raise the head of the bed and administer oxygen. Stopping the transfusion can follow after the client's respiratory status stabilizes.

Questions

A. Administering oxygen via a non-rebreather mask. B. Discontinuing the blood transfusion immediately. C. Elevating the client's feet and lowering the head. D. Administering diuretics to manage fluid overload.

Correct Answer is A

Explanation

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.

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A client is scheduled to receive a blood transfusion, but the nurse discovers that the blood product appears discolored or contains clots. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receiving a blood transfusion develops sudden chest pain, dyspnea, and a productive cough with pink, frothy sputum. The nurse suspects a severe transfusion reaction. What is the nurse's immediate action?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

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