Nurse Jay is caring for a client with an ongoing transfusion of packed RBCs when suddenly the client is having difficulty of breathing, skin is flushed and having chills. Which action should nurse jay take first?

TRANSFUSION

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Question [CLICK ON ANY CHOICE TO KNOW THE RIGHT ANSWER]

Nurse Jay is caring for a client with an ongoing transfusion of packed RBC’s when suddenly the client is having difficulty of breathing, skin is flushed and having chills. Which action should nurse jay take first?

A	Administer oxygen.
B	Place the client on droplight
C	Check the client’s temperature
D	Stop the transfusion.

Explanation:

Detailed explanation-1: -Answer: D. Stop the transfusion. The client in this situation is experiencing transfusion reaction so the priority action of the nurse is to first stop the transfusion.

Detailed explanation-2: -As soon as you suspect a transfusion reaction: Stop the transfusion immediately and activate emergency procedures if required. Check and monitor the patient’s vital signs. Maintain intravenous (IV) access (do not flush the existing line and use a new IV line if required).

Detailed explanation-3: -After terminating the transfusion during a reaction, which action should the nurse immediately be taken next? Run a solution of 5% dextrose in water.

Detailed explanation-4: -Which nursing intervention takes highest priority when caring for a newly admitted client who’s receiving a blood transfusion? Instructing the client to report any itching, chest pain, or dyspnea. Rationale: This will help the nurse take immediate action incase a reaction happens during a transfusion.

There is 1 question to complete.

AP BIOLOGY

THE HUMAN IMMUNE SYSTEM

TRANSFUSION