Ati lpn med surg haematology
Ati lpn med surg haematology ( 32 Questions)
A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?
Stop the transfusion: Stopping the transfusion is the priority action to prevent further exposure to the antigen causing the reaction.
Administer diphenhydramine: Administering diphenhydramine is an appropriate intervention for allergic reactions, but stopping the transfusion should be done first to halt the reaction source.
Obtain vital signs. Obtaining vital signs is important but should follow stopping the transfusion to address the immediate risk of reaction.
Notify the registered nurse: Notifying the registered nurse is necessary but comes after stopping the transfusion to immediately mitigate the reaction.
A. Stop the transfusion: Stopping the transfusion is the priority action to prevent further exposure to the antigen causing the reaction.
B. Administer diphenhydramine: Administering diphenhydramine is an appropriate intervention for allergic reactions, but stopping the transfusion should be done first to halt the reaction source.
C. Obtain vital signs. Obtaining vital signs is important but should follow stopping the transfusion to address the immediate risk of reaction.
D. Notify the registered nurse: Notifying the registered nurse is necessary but comes after stopping the transfusion to immediately mitigate the reaction.