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.
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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Related Questions
Correct Answer is D
Explanation
A) Incorrect: A slight increase in blood pressure is not a significant vital sign alteration that requires immediate reporting before initiating the transfusion. It could be related to various factors, such as anxiety or pain.
B) Incorrect: A respiratory rate of 22 breaths per minute is within the normal range for an adult and does not require immediate reporting before starting the transfusion.
C) Incorrect: A decrease in heart rate from 88 to 72 beats per minute is not a critical vital sign alteration. As long as the heart rate remains within the client's baseline range, it does not need immediate reporting.
D) Correct: An elevated temperature of 38.5°C (101.3°F) may indicate a fever, which could be a sign of an infection or an adverse reaction to the transfusion. The nurse should report this vital sign alteration to the healthcare provider before proceeding with the transfusion to determine the appropriate course of action.
Correct Answer is A
Explanation
A) Stopping the blood transfusion immediately is the nurse's priority action if a transfusion reaction is suspected. This helps prevent further infusion of the potentially incompatible or problematic blood product.
B) Notifying the blood bank is essential to report the suspected transfusion reaction and to facilitate investigation and documentation. However, stopping the transfusion is the first step.
C) Administering antipyretics may help manage the client's fever, but it is not the nurse's priority action when a transfusion reaction is suspected.
D) Placing the client in a supine position with legs elevated is not a priority action when a transfusion reaction is suspected. The priority is to stop the transfusion and assess the client's vital signs and symptoms.
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