A nurse is caring for a client who develops urticaria (hives) and itching during a blood transfusion. The nurse suspects an allergic transfusion reaction. What is the appropriate nursing action?
Administer epinephrine immediately.
Stop the transfusion and disconnect the IV tubing.
Slow down the transfusion rate.
Obtain a blood sample for repeat crossmatching.
The Correct Answer is C
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.
Questions
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect: Fresh Frozen Plasma (FFP) is not the appropriate blood product for immediate volume replacement. It contains clotting factors and is used to manage bleeding disorders.
B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction and do not provide volume replacement.
C) Correct: Packed Red Blood Cells (PRBCs) contain red blood cells and are used for volume replacement in clients with acute blood loss or anemia.
D) Incorrect: Albumin is used for volume expansion in cases of hypoalbuminemia and fluid resuscitation in certain situations, but PRBCs are more effective for rapid volume replacement.
Correct Answer is C
Explanation
A) Incorrect: Mild itching on the client's forearms is a common and expected side effect of a blood transfusion and may not require immediate reporting to the healthcare provider.
B) Incorrect: Mild lower back pain that subsides is not a significant finding and may not require immediate reporting to the healthcare provider.
C) Correct: An increase in blood pressure by 10 mmHg from the client's baseline may indicate a potential transfusion reaction or fluid overload. The nurse should report this finding to the healthcare provider for further evaluation.
D) Incorrect: An increase in hemoglobin level by 2 g/dL after the transfusion is a positive outcome, indicating a successful transfusion. There is no need to report this finding to the healthcare provider.
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