A nurse is assessing a client who just received a blood transfusion. The client complains of back pain, fever, and chills. What action should the nurse take first?
Notify the healthcare provider immediately.
Administer acetaminophen to reduce the fever.
Stop the transfusion and disconnect the IV tubing.
Infuse normal saline to maintain the client's hydration.
The Correct Answer is C
A. Notifying the healthcare provider is important but should be done after stopping the transfusion to prevent further reaction.
B. Administering acetaminophen does not address the underlying cause of the reaction and should not be the priority.
C. Stopping the transfusion and disconnecting the IV tubing is the first priority to prevent further exposure to the incompatible blood product, which could lead to a life-threatening hemolytic reaction.
D. Infusing normal saline is appropriate to maintain hydration, but it should be done after stopping the transfusion.
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Related Questions
Correct Answer is C
Explanation
A) Incorrect: Transfusing whole blood increases the risk of adverse reactions and is not commonly used in modern transfusion practices. Whole blood is usually separated into its individual components for transfusion.
B) Incorrect: Fresh frozen plasma (FFP) contains various clotting factors and is used primarily to treat bleeding disorders and coagulopathies, not to prevent transfusion reactions.
C) Correct: Packed red blood cells (PRBCs) contain primarily red blood cells without significant amounts of plasma, white blood cells, or platelets. For clients with a history of transfusion reactions, PRBCs are the most suitable blood component to minimize the risk of future reactions.
D) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction but do not provide the main benefit of minimizing the risk of future transfusion reactions as PRBCs do.
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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