NUR105 M4.3: ATI-Video Case Studies: Safety – Blood Transfusion
Question: A nurse is caring for a client who has indications of a febrile blood transfusion reaction. After stopping the transfusion, which of the following medications should the nurse expect the provider to prescribe?NUR105 M4.3: ATI-Video Case Studies
Answer: Antipyretic
Explanation: The nurse should expect a prescription for an antipyretic to treat the client’s fever. Febrile blood transfusion reactions can be manifested by fever, chills, headache, flushing, anxiety, and muscle pain.NUR105 M4.3: ATI-Video Case Studies
Question: A nurse is caring for a client who is receiving a blood transfusion and experiences a 1-degree increase in temperature. Which of the following transfusion reactions should the nurse suspect?NUR105 M4.3: ATI-Video Case Studies
Answer: Febrile. NUR105 M4.3: ATI-Video Case Studies
Explanation: The nurse should recognize that a minimal increase in temperature can indicate a febrile transfusion reaction.
Question: A nurse is caring for a client who has a prescription for a transfusion of a unit of packed RBCs. Which of the following actions should take place prior to the initiation of the transfusion?
Answer: The unit of blood should be verified against the client’s data.
Explanation: Prior to initiating a transfusion, the information on the unit of blood should be verified against the client’s data to ensure the blood is appropriate to administer.
Question: A nurse is caring for a client who has indications of a blood transfusion reaction. Which of the following actions should the nurse take first?
Answer: Stop the transfusion.
Explanation: The greatest risk to this client is injury from a transfusion reaction. Therefore, the first action the nurse should take is to stop the transfusion.
Question: A nurse is caring for a client who is receiving a blood transfusion and is experiencing manifestations of a reaction. After stopping the transfusion, which of the following actions should the nurse take?
Answer: Obtain the client’s vital signs.
Explanation: Following the discontinuation of the transfusion, the nurse should obtain the client’s latest vital signs and report the incident to the provider. The nurse should continue to monitor the client’s vital signs frequently, or as prescribed by the provider, to ensure the client is stable.
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