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?
Raise the head of the client's bed and administer oxygen.
Obtain a sputum sample for culture and sensitivity testing.
Administer a diuretic to relieve pulmonary congestion.
Discontinue the blood transfusion and remove the IV catheter.
The Correct Answer is A
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct: The client's symptoms of hives, itching, and facial swelling indicate a potential allergic transfusion reaction (urticarial reaction). The nurse's immediate action is to stop the transfusion immediately and notify the healthcare provider for further evaluation and intervention.
B) Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic transfusion reaction, it is not the immediate action. The nurse should first stop the transfusion and notify the healthcare provider.
C) Incorrect: Slowing down the transfusion rate is not appropriate in the presence of an allergic transfusion reaction. The nurse should stop the transfusion immediately.
D) Incorrect: Placing the client in a supine position with legs elevated is not indicated for an allergic transfusion reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.
Correct Answer is D
Explanation
A) Incorrect: Discontinuing the blood transfusion may be necessary if the allergic reaction is severe, but it is not the appropriate action for a mild allergic reaction. The nurse should manage the current reaction and take preventive measures for future transfusions.
B) Incorrect: Administering an antihistamine is appropriate to manage the current allergic reaction,but it may not prevent future allergic reactions. The nurse should focus on preventing allergic reactions in future transfusions.
C) Incorrect: Notifying the healthcare provider is important for appropriate management, but it may not directly prevent future allergic reactions. The nurse should implement preventive measures.
D) Correct: Obtaining a sample for repeat crossmatching is essential to identify and select blood products that are less likely to cause an allergic reaction in the client. This step can help prevent future allergic transfusion reactions and ensure safer blood product selection.
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