A client who received a blood transfusion 2 hours ago is now experiencing symptoms of a transfusion reaction, including fever, chills, and shortness of breath. What is the nurse's priority action?
Notify the healthcare provider immediately.
Administer antipyretics to lower the client's fever.
Prepare to administer a diuretic to manage fluid overload.
Discontinue the blood transfusion immediately.
The Correct Answer is A
A: Notifying the healthcare provider is an important step, but it is not the immediate priority. The nurse's first action should be to address the adverse reaction to prevent further harm to the client.
B: While administering antipyretics may help lower the client's fever, it does not address the underlying cause of the symptoms, which is the transfusion reaction. The priority is to stop the reaction from progressing.
C: Preparing to administer a diuretic would be appropriate if fluid overload was the primary concern. However, in the case of a transfusion reaction, the priority is to stop the transfusion to halt the reaction.
D: Discontinuing the blood transfusion immediately is the priority action because it stops the exposure to the blood product that is causing the reaction. Once the transfusion is stopped, further interventions can be assessed and implemented.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Platelets should be infused rapidly, typically over 30 to 60 minutes, to prevent clotting and ensure effectiveness.
B. A specialized platelet administration set with a filter should be used, not a standard IV infusion set.
C. Although ABO compatibility is less critical for platelets than for red blood cell transfusions, compatibility should still be verified to reduce the risk of reactions.
D. Platelets should not be warmed; they should be stored at room temperature and gently agitated to prevent clumping.
Correct Answer is D
Explanation
A) Incorrect: While explaining the blood transfusion procedure is essential, doing so in excessive detail may increase the client's anxiety. The nurse should provide information in a clear and concise manner, addressing the client's specific concerns.
B) Incorrect: Offering a warm blanket is a comfort measure but may not be sufficient to address the client's anxiety and fear about the transfusion. The nurse should engage in therapeutic communication and provide emotional support.
C) Incorrect: Requesting a sedative for the client may not be the best course of action unless specifically prescribed by the healthcare provider. It is essential to explore other interventions to address the client's anxiety before resorting to medication.
D) Correct: Providing the client with information about the benefits and risks of the transfusion can help alleviate their anxiety and fear. The nurse should engage in patient education, discuss the purpose of the transfusion, potential benefits, and possible risks involved. This empowers the client with knowledge and helps them make informed decisions.
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