Fundamentals of Nursing Q 430
Nurse Jay is caring for a client with an ongoing transfusion of packed RBCs when suddenly the client is having difficulty breathing, skin is flushed, and having chills. Which action should nurse Jay take first?
A. Administer oxygen.
B. Place the client on a droplight.
C. Check the client's temperature.
D. Stop the transfusion.
Correct Answer: D. Stop the transfusion.
The client in this situation is experiencing a transfusion reaction so the priority action of the nurse is to first stop the transfusion. Disconnect the transfusion set-but keep the IV line open with 0.9% saline to provide access for possible IV drug infusion. Send the blood bag and tubing to the blood bank for repeat typing and culture.
Option A: Place the client in Fowler’s position with shortness of breath and administer O2 therapy. The nurse remains with the client, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. Obtain a urine specimen and send it to the laboratory to determine presence of hemoglobin as a result of RBC hemolysis.
Option B: Placing the client under a drop light would not manage his difficulty in breathing. For circulatory overload, immediate treatment includes positioning the patient upright with feet dependent; diuretics, oxygen, and aminophylline may be prescribed. The nurse prepares to administer emergency drugs such as antihistamines, vasopressor, fluids, and steroids as per the physician’s order or protocol.
Option C: Febrile, nonhemolytic transfusion reactions are treated symptomatically with antipyretics; leukocyte-poor blood products may be recommended for subsequent transfusions. Blood container, tubing, attached label, and transfusion record are saved and returned to the laboratory for analysis.