Practice Question
A patient receiving a blood transfusion suddenly develops chest pain, decreased blood pressure, and dyspnea. What is the most appropriate initial action for the nurse to take?
Answer Choices:
Correct Answer:
Stop the transfusion immediately and notify the physician, nursing supervisor, and the blood bank.
Rationale:
🔷 The first priority when a transfusion reaction is suspected is to stop the transfusion immediately to prevent further administration of the potentially incompatible blood product.
🔷 Chest pain, dyspnea, and hypotension are classic signs of a severe transfusion reaction, possibly acute hemolytic or anaphylactic reaction, which can be life-threatening.
🔷 After stopping the transfusion, the IV line is kept open with normal saline to maintain venous access and avoid circulatory collapse.
🔷 Prompt notification of the physician, nursing supervisor, and blood bank ensures that appropriate interventions such as administering oxygen, antihistamines, or vasopressors can be initiated.
🔷 Immediate action also allows for blood samples and the transfused unit to be returned to the blood bank for analysis to prevent future errors.
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Custom - (MS) PNV 1682 Comprehensive Final KB! - Blue Cliff College Gulfport Campus PN
77 Questions
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- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Adult Health
- Answer Choices: 4