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.

None

Answer and Explanation

The Correct Answer is D

A. Notifying the healthcare provider is important, but the immediate priority is to stop the transfusion to prevent further exposure to the potential offending blood product.

B. Administering antipyretics addresses fever but does not stop the transfusion, so it does not prevent worsening of a potentially serious reaction.

C. Preparing a diuretic may be appropriate for fluid overload, but the symptoms described (fever, chills, shortness of breath) suggest a transfusion reaction, not just fluid overload. Immediate action is needed to prevent harm.

D. Discontinuing the blood transfusion immediately is the priority action because it prevents additional exposure to the blood product causing the reaction and is the first step in transfusion reaction protocols.

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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.

A. Fresh Frozen Plasma (FFP) B. Platelets C. Packed Red Blood Cells (PRBCs) D. Albumin

Correct Answer is B

Explanation

A) Incorrect: Fresh Frozen Plasma (FFP) contains clotting factors and is used to treat bleeding disorders, but it is not primarily responsible for promoting clot formation and controlling bleeding.

B) Correct: Platelets are responsible for promoting clot formation and controlling bleeding. They play a crucial role in hemostasis and are used to treat thrombocytopenia and platelet dysfunction.

C) Incorrect: Packed Red Blood Cells (PRBCs) primarily carry oxygen and are used to treat anemia and improve oxygenation, but they do not have a direct role in clot formation or controlling bleeding.

D) Incorrect: Albumin is a protein used to expand intravascular volume, especially in cases of hypoalbuminemia, but it does not have a significant role in clot formation or controlling bleeding.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a platelet transfusion to a client with severe thrombocytopenia. The nurse should:

Correct Answer is C

Explanation

A nurse is preparing to administer a blood component to a client. Which blood component is responsible for promoting clot formation and controlling bleeding?

Correct Answer is B

Explanation

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