A nurse is caring for a client who experiences an acute hemolytic transfusion reaction. What intervention should the nurse anticipate implementing?

Administering antipyretics to reduce fever.

Preparing to administer a diuretic to manage fluid overload.

Monitoring the client's vital signs frequently.

Administering epinephrine to counteract an allergic reaction.

Answer and Explanation

The Correct Answer is C

A) Incorrect: Administering antipyretics to reduce fever is not the appropriate intervention for an acute hemolytic transfusion reaction. This type of reaction involves the destruction of red blood cells, not an elevation in body temperature.

B) Incorrect: Preparing to administer a diuretic is not the appropriate intervention for an acute hemolytic transfusion reaction. Fluid overload is not a typical feature of this type of reaction.

C) Correct: Monitoring the client's vital signs frequently is a crucial intervention for an acute hemolytic transfusion reaction. This type of reaction can cause rapid onset of severe symptoms, including fever, chills, hypotension, tachycardia, and potential shock.

D) Incorrect: Administering epinephrine is not the appropriate intervention for an acute hemolytic transfusion reaction. Epinephrine is used to treat anaphylactic reactions, not hemolytic reactions.

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Correct Answer is A

Explanation

A) Correct: Fresh Frozen Plasma (FFP) contains various clotting factors and is used to treat clotting factor deficiencies such as those found in coagulopathies or liver disease.

B) Incorrect: Platelets are used to treat thrombocytopenia and platelet dysfunction, not clotting factor deficiencies.

C) Incorrect: Cryoprecipitate is derived from FFP and contains concentrated fibrinogen and other clotting factors. It is used for specific clotting factor deficiencies but is not the primary treatment for clotting factor deficiencies in general.

D) Incorrect: Packed Red Blood Cells (PRBCs) are used to treat anemia and improve oxygenation but do not address clotting factor deficiencies.

A. Verify the client's identity and blood type with two unique identifiers. B. Confirm the expiration date of the blood product. C. Assess the client's vital signs, including temperature, pulse, and blood pressure. D. Obtain informed consent from the client for the blood transfusion.

Correct Answer is A

Explanation

A) Correct: The nurse should verify the client's identity and blood type with two unique identifiers, such as asking the client to state their full name and date of birth and comparing it to their identification band. This step ensures that the correct blood product is administered to the right client, promoting safety.

B) Incorrect: Confirming the expiration date of the blood product is important but not the first step in ensuring client safety during a blood transfusion. The nurse should first verify the client's identity and blood type.

C) Incorrect: Assessing the client's vital signs is essential, but it is not the first action to be taken. Verifying the client's identity and blood type is the priority before starting the transfusion.

D) Incorrect: Obtaining informed consent from the client is crucial but not the first action to be taken. The nurse should first verify the client's identity and blood type before seeking consent for the transfusion.

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A nurse is caring for a client who experiences an acute hemolytic transfusion reaction. What intervention should the nurse anticipate implementing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a blood product to a client with a clotting factor deficiency. Which blood product should the nurse anticipate administering?

Correct Answer is A

Explanation

A nurse is preparing to initiate a blood transfusion for a client. Which action should the nurse take first to ensure client safety?

Correct Answer is A

Explanation

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