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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Questions
Correct Answer is C
Explanation
A) Incorrect: Administering epinephrine is not the appropriate intervention for an allergic transfusion reaction characterized by urticaria and itching. Epinephrine is used to treat anaphylactic reactions.
B) Incorrect: Stopping the transfusion and disconnecting the IV tubing is appropriate in the event of an allergic transfusion reaction, but it should not be the first action. The nurse should first slow down or stop the transfusion if mild symptoms are present and notify the healthcare provider for further instructions.
C) Correct: Slowing down the transfusion rate may be appropriate for mild allergic reactions to reduce symptoms. However, if the reaction worsens, the nurse should stop the transfusion immediately.
D) Incorrect: Obtaining a blood sample for repeat crossmatching is not indicated in an allergic transfusion reaction. Allergic reactions are related to hypersensitivity to plasma proteins and do not involve compatibility issues between red blood cells and plasma.
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