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 D
Explanation
A) Incorrect: Fresh Frozen Plasma (FFP) contains clotting factors and is not the primary treatment for hypoalbuminemia.
B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction, not hypoalbuminemia.
C) Incorrect: Packed Red Blood Cells (PRBCs) are primarily used to improve oxygenation in anemic clients and do not address hypoalbuminemia.
D) Correct: Albumin is the blood product of choice for addressing severe hypoalbuminemia. It is a protein that helps maintain oncotic pressure and regulates fluid balance within the blood vessels.
Correct Answer is B
Explanation
A) Incorrect: Obtaining a signed informed consent is an essential step before administering a blood transfusion, but it is not the priority action for preventing a potential complication related to blood compatibility. The nurse should first confirm the client's blood type and Rh factor.
B) Correct: The nurse's priority action is to confirm the client's blood type and Rh factor with two unique identifiers to ensure compatibility between the client and the blood product. This step is crucial for preventing transfusion reactions due to ABO and Rh incompatibility.
C) Incorrect: Ensuring that the blood product is properly labeled and has not expired is important for patient safety but is not the priority action before administering a blood transfusion. The nurse should first confirm the client's blood type and Rh factor.
D) Incorrect: Assessing the client's vital signs and baseline laboratory values is essential, but it is not the priority action for preventing a potential complication related to blood compatibility. The nurse should first confirm the client's blood type and Rh factor.
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