A nurse is monitoring a client who is receiving a blood transfusion. After 15 minutes of starting the transfusion, the client develops hives, itching, and facial swelling. What is the nurse's immediate action?

Slow down the transfusion rate.

Elevate the client's feet and lower the head.

Discontinue the transfusion and infuse normal saline.

Administer an antihistamine as prescribed.

Answer and Explanation

The Correct Answer is C

A) Incorrect: Slowing down the transfusion rate is not the appropriate action in this scenario. The client is experiencing signs of an allergic reaction, and the nurse must act promptly to address the situation.

B) Incorrect: Elevating the client's feet and lowering the head (Trendelenburg position) is not indicated for an allergic reaction. It may be used for clients in shock, but the priority is to manage the allergic reaction.

C) Correct: The nurse should immediately discontinue the transfusion and initiate the infusion of normal saline to maintain the client's intravascular volume. Discontinuing the blood transfusion helps prevent further exposure to the allergen (if an allergic reaction is confirmed) and addresses fluid volume needs.

D) Incorrect: While administering an antihistamine may be part of the treatment plan for an allergic reaction, it is not the immediate action. The nurse should first discontinue the transfusion and infuse normal saline as stated in option C.

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Correct Answer is A

Explanation

A) Correct: Pre-medicating the client with antihistamines before the transfusion can help prevent or minimize allergic transfusion reactions in clients with a history of severe allergies. Antihistamines block histamine release, reducing the risk of allergic symptoms.

B) Incorrect: Administering the blood transfusion rapidly is not a preventive measure for allergic transfusion reactions. In fact, rapid administration may increase the risk of adverse reactions.

C) Incorrect: Warming the blood product before administration is important to prevent hypothermia but is not directly related to preventing allergic transfusion reactions.

D) Incorrect: Monitoring the client's vital signs during the transfusion is a standard practice, but it is not the primary intervention for preventing allergic transfusion reactions. Pre-medication with antihistamines is a more targeted approach.

A. Stop the blood transfusion immediately. B. Notify the blood bank to request a new blood unit. C. Administer antipyretics to manage the client's fever. D. Place the client in a supine position with legs elevated.

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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A nurse is monitoring a client who is receiving a blood transfusion. After 15 minutes of starting the transfusion, the client develops hives, itching, and facial swelling. What is the nurse's immediate action?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

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