Hemorrhage

Hemorrhage ( 40 Questions)

A nurse is caring for a client who experienced a hemorrhage and received a blood transfusion. The client reports sudden difficulty breathing and chest pain. What is the nurse's immediate action?


Correct Answer: C

A) Incorrect. Administering oxygen is essential for a client experiencing difficulty breathing, but the nurse's immediate action should be to stop the blood transfusion and notify the healthcare provider.

B) Incorrect. While assessing the client's vital signs is important, the priority action is to stop the blood transfusion and seek immediate medical assistance.

C) Correct. Sudden difficulty breathing and chest pain after a blood transfusion may indicate an allergic reaction or transfusion-related acute lung injury (TRALI). The nurse should stop the transfusion immediately and inform the healthcare provider.

D) Incorrect. Elevating the head of the client's bed may be helpful in managing respiratory distress, but it is not the priority when there is a potential adverse reaction to the blood transfusion.




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