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.
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Related Questions
Correct Answer is D
Explanation
A) Incorrect: Discontinuing the blood transfusion may be necessary if the allergic reaction is severe, but it is not the appropriate action for a mild allergic reaction. The nurse should manage the current reaction and take preventive measures for future transfusions.
B) Incorrect: Administering an antihistamine is appropriate to manage the current allergic reaction,but it may not prevent future allergic reactions. The nurse should focus on preventing allergic reactions in future transfusions.
C) Incorrect: Notifying the healthcare provider is important for appropriate management, but it may not directly prevent future allergic reactions. The nurse should implement preventive measures.
D) Correct: Obtaining a sample for repeat crossmatching is essential to identify and select blood products that are less likely to cause an allergic reaction in the client. This step can help prevent future allergic transfusion reactions and ensure safer blood product selection.
Correct Answer is A
Explanation
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.
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