A nurse is reviewing a client's blood compatibility results before a blood transfusion. The crossmatch shows agglutination and incompatibility between the donor's red blood cells and the client's plasma. What action should the nurse take?

A) Raising the head of the client's bed and administering oxygen is the immediate action to improve oxygenation and relieve respiratory distress in a client experiencing potential pulmonary edema, as evidenced by the pink, frothy sputum.

B) Obtaining a sputum sample for culture and sensitivity testing may be important to assess for infection, but it is not the nurse's immediate action in response to a severe transfusion reaction.

C) Administering a diuretic may help with pulmonary congestion, but it is not the nurse's immediate action in response to a severe transfusion reaction. The priority is to improve oxygenation.

D) Discontinuing the blood transfusion and removing the IV catheter is important, but the immediate action to address the client's respiratory distress is to raise the head of the bed and administer oxygen. Stopping the transfusion can follow after the client's respiratory status stabilizes.

Questions

A) Incorrect: Administering the blood transfusion when agglutination and incompatibility are detected is unsafe and may lead to severe transfusion reactions. The nurse should not proceed with the transfusion.

B) Correct: In the presence of agglutination and incompatibility between the donor's red blood cells and the client's plasma, the nurse must discontinue the blood transfusion immediately and return the blood to the blood bank. This ensures the client's safety and prevents further adverse reactions.

C) Incorrect: Increasing the infusion rate will not resolve the incompatibility issue and may worsen the client's condition. The nurse should stop the transfusion promptly.

D) Incorrect: Mixing the incompatible blood with normal saline will not resolve the incompatibility issue and is not a safe practice. The nurse should not proceed with the transfusion and should return the blood to the blood bank.