A nurse is monitoring a client who just received a blood transfusion. The client suddenly develops dyspnea, tachycardia, and chest pain. What is the nurse's priority action?

Elevate the head of the bed to promote lung expansion.

Administer diuretics to manage fluid overload.

Stop the transfusion immediately and notify the healthcare provider.

Document the client's symptoms and continue the transfusion at a slower rate.

Answer and Explanation

The Correct Answer is C

A) Incorrect: Elevating the head of the bed may help promote lung expansion, but it is not the nurse's priority action when the client is experiencing severe symptoms like dyspnea, tachycardia, and chest pain during a transfusion.

B) Incorrect: Administering diuretics is not the appropriate action for the client's symptoms, which suggest a possible transfusion-related acute lung injury (TRALI) or acute hemolytic transfusion reaction. Diuretics will not address the underlying cause.

C) Correct: The client's symptoms of dyspnea, tachycardia, and chest pain indicate a potential severe transfusion reaction. The nurse's priority action is to stop the transfusion immediately and notify the healthcare provider for further evaluation and intervention.

D) Incorrect: Continuing the transfusion at a slower rate is not appropriate when the client is experiencing severe symptoms. The nurse should first stop the transfusion and then notify the healthcare provider.

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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.

A. "You may experience a mild fever and chills during the transfusion, which is normal." B. "If you develop any itching, rash, or facial swelling, please notify me immediately." C. "Expect a brief period of increased heart rate after the transfusion is completed." D. "It is common to have lower back pain after receiving a blood transfusion."

Correct Answer is B

Explanation

A) Incorrect: Fever and chills during a blood transfusion may be signs of a febrile transfusion reaction, not an allergic reaction. The nurse should provide information specific to preventing allergic reactions.

B) Correct: Itching, rash, and facial swelling are common signs of an allergic transfusion reaction. The nurse should instruct the client to notify the healthcare provider immediately if they experience these symptoms.

C) Incorrect: A brief period of increased heart rate after the transfusion may be normal, but it is not specific to preventing an allergic transfusion reaction. The nurse should focus on providing information about allergic reaction symptoms.

D) Incorrect: Lower back pain is not typically associated with allergic transfusion reactions. The nurse should provide information about symptoms that indicate an allergic reaction, such as itching, rash, and facial swelling.

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A nurse is monitoring a client who just received a blood transfusion. The client suddenly develops dyspnea, tachycardia, and chest pain. What is the nurse's priority action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a blood transfusion to a client. Which vital sign alteration should the nurse report to the healthcare provider before initiating the transfusion?

Correct Answer is D

Explanation

A nurse is caring for a client who is about to receive a blood transfusion. What information should the nurse provide to the client to prevent an allergic transfusion reaction?

Correct Answer is B

Explanation

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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