A nurse is monitoring a client who is receiving a blood transfusion. Which of the following
findings indicates an allergic transfusion reaction?
• Blood pressure 184/92 mm Hg.
• Generalized urticaria.
• Distended jugular veins.
• Bilateral flank pain. - Answers Generalized urticaria.
A client in the emergency department reports back pain and difficulty breathing 15 minutes after
a transfusion of packed red blood cells is started. What should the nurse's first action be?
• Obtain a urine specimen to send to the laboratory.
• Disconnect the transfusion and infuse normal saline.
• Notify the health care provider about the symptoms.
• Administer oxygen therapy at a high flowrate. - Answers Disconnect the transfusion and infuse
normal saline.
A nurse suspects anaphylaxis when caring for a client following the initial administration of an
oral antibiotic. Which of the following should be the nurse's priority action?
• Administer oxygen.
, • Prepare equipment for intubation.
• Count the respiratory rate.
• Insert an IV line. - Answers Count the respiratory rate.
A nurse remains with a client to observe for any adverse reactions after initiating a transfusion
of packed RBCs. The client becomes apprehensive and tachycardic, reporting headache and low
back pain. The nurse should recognize that these findings indicate which of the following
transfusion reactions?
• Bacterial
• Febrile
• Hemolytic
• Allergic - Answers Hemolytic
A postoperative client receiving a transfusion of packed red blood cells develops chills, fever,
headache, and anxiety 35 minutes after the transfusion is started. After stopping the
transfusion, what action should the nurse take?
• Draw blood for a new type and crossmatch.
• Send a urine specimen to the laboratory.
• Give the prescribed PRN diphenhydramine.