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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct: Red blood cells are the main blood component involved in the crossmatching process. Crossmatching ensures compatibility between the donor's red blood cells and the recipient's plasma, preventing adverse reactions during the transfusion.
B) Incorrect: White blood cells are not part of the crossmatching process. They play a role in the immune response but are not specifically assessed during crossmatching.
C) Incorrect: Platelets are not directly involved in the crossmatching process. Crossmatching primarily focuses on red blood cell compatibility.
D) Incorrect: Plasma is not directly involved in the crossmatching process. The focus is on ensuring compatibility between red blood cells and the recipient's plasma.
Correct Answer is B
Explanation
A) Incorrect: Administering a bolus of normal saline may help increase intravascular volume, but it is not the first intervention to be implemented. The nurse should first identify the cause of the client's symptoms and take appropriate actions.
B) Correct: The client's symptoms of feeling lightheaded and dizzy, along with a drop in blood pressure and an increase in heart rate, suggest orthostatic hypotension. The nurse's first intervention should be to elevate the client's feet and lower the head to improve blood flow to the brain.
C) Incorrect: Checking the client's hemoglobin and hematocrit levels is essential but may not be the first intervention in this situation. The client's symptoms indicate an immediate need to address the orthostatic hypotension.
D) Incorrect: Notifying the healthcare provider for further evaluation is important, but it may not be the first intervention. The nurse should first take immediate actions to address the client's symptoms of orthostatic hypotension.
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