A client receiving a blood transfusion suddenly develops chills, fever, and lower back pain. The nurse suspects a transfusion reaction. What is the nurse's priority action?
Stop the blood transfusion immediately.
Notify the blood bank to request a new blood unit.
Administer antipyretics to manage the client's fever.
Place the client in a supine position with legs elevated.
The Correct Answer is A
A) Stopping the blood transfusion immediately is the nurse's priority action if a transfusion reaction is suspected. This helps prevent further infusion of the potentially incompatible or problematic blood product.
B) Notifying the blood bank is essential to report the suspected transfusion reaction and to facilitate investigation and documentation. However, stopping the transfusion is the first step.
C) Administering antipyretics may help manage the client's fever, but it is not the nurse's priority action when a transfusion reaction is suspected.
D) Placing the client in a supine position with legs elevated is not a priority action when a transfusion reaction is suspected. The priority is to stop the transfusion and assess the client's vital signs and symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect: Placing the client in a supine position with legs elevated is not appropriate in this situation. The client is showing signs of a potential severe allergic reaction (anaphylaxis) or a transfusion-related acute lung injury (TRALI), and the nurse should prioritize interventions accordingly.
B) Correct: Administering oxygen via a non-rebreather mask is the appropriate immediate action for a client experiencing respiratory distress and muffled heart sounds. This intervention helps improve oxygenation and respiratory function.
C) Incorrect: Checking the client's temperature and administering antipyretics is not indicated as the client's symptoms are not consistent with a fever. The focus should be on respiratory and cardiovascular support.
D) Incorrect: Stopping the blood transfusion is essential, but it is not the immediate action in this situation. The nurse's priority is to address the client's respiratory distress and ensure adequate oxygenation by administering oxygen, as stated in option B. Once the client is stable, the nurse should then notify the healthcare provider about the situation.
Questions
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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