A nurse is monitoring a client during a blood transfusion. The client suddenly develops hives, itching, and facial swelling. What is the nurse's immediate action?

Stop the transfusion immediately and notify the healthcare provider.

Administer an antihistamine to manage the allergic reaction.

Slow down the transfusion rate to observe for further reactions.

Place the client in a supine position with legs elevated.

Answer and Explanation

The Correct Answer is A

A) Correct: The client's symptoms of hives, itching, and facial swelling indicate a potential allergic transfusion reaction (urticarial reaction). The nurse's immediate action is to stop the transfusion immediately and notify the healthcare provider for further evaluation and intervention.

B) Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic transfusion reaction, it is not the immediate action. The nurse should first stop the transfusion and notify the healthcare provider.

C) Incorrect: Slowing down the transfusion rate is not appropriate in the presence of an allergic transfusion reaction. The nurse should stop the transfusion immediately.

D) Incorrect: Placing the client in a supine position with legs elevated is not indicated for an allergic transfusion reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.

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Correct Answer is C

Explanation

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.

A. Infuse the platelets slowly over 4 hours. B. Use a standard IV infusion set for administration. C. Verify compatibility with the client's blood type. D. Warm the platelets to room temperature before infusion.

Correct Answer is C

Explanation

A. Platelets should be infused rapidly, typically over 30 to 60 minutes, to prevent clotting and ensure effectiveness.
B. A specialized platelet administration set with a filter should be used, not a standard IV infusion set.
C. Although ABO compatibility is less critical for platelets than for red blood cell transfusions, compatibility should still be verified to reduce the risk of reactions.
D. Platelets should not be warmed; they should be stored at room temperature and gently agitated to prevent clumping.

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