Question

A client receiving a blood transfusion exhibits lower back pain, fever, and dyspnea. What is the nurse's initial action? A. Stop the blood transfusion and keep the vein open with normal saline B. Administer epinephrine per unit protocol C. Notify the physician D. Obtain a set of vital signs

Short answer

Answer: A. Stop the blood transfusion and keep the vein open with normal saline.

Step-by-step solution

Understanding the symptoms

Lower back pain, fever, and dyspnea are signs that the client might be experiencing a blood transfusion reaction. This could be a serious condition that requires prompt action from the nurse.

Evaluating the options

Now let's evaluate each given option to determine the most appropriate initial action for the nurse: A. Stop the blood transfusion and keep the vein open with normal saline. B. Administer epinephrine per unit protocol. C. Notify the physician. D. Obtain a set of vital signs.

Identifying the priority

In a potential blood transfusion reaction, the priority is to stop the transfusion immediately to prevent further harm to the client. So, option A seems the most appropriate action in this scenario.

Assessing secondary actions

After stopping the transfusion and maintaining venous access with saline, the nurse should then take the client's vital signs, notify the physician, and follow any additional protocols as needed. These actions correspond to option C and D, and may follow the initial action of stopping the transfusion.

Eliminating inappropriate option

Option B, administering epinephrine, is not the initial action the nurse should take. Epinephrine may be administered if the client exhibits anaphylactic symptoms during the transfusion, but it should not be the nurse's first action in this scenario.

Final Answer

Based on the analysis, the nurse's initial action in this scenario should be: A. Stop the blood transfusion and keep the vein open with normal saline.

Key concepts

Nursing Intervention

Nursing interventions are crucial in the response to a blood transfusion reaction. Recognizing the signs of a reaction, such as lower back pain, fever, and dyspnea, is the first and most critical intervention. The responsibility of the nurse, in this case, is to act rapidly to mitigate any potential harm to the patient.

The nurse must immediately stop the blood transfusion, as continuing could exacerbate the reaction and result in more severe complications. Keeping the vein open with normal saline ensures that the patient maintains intravenous access, which is essential for administering medications or fluids required in managing the reaction. This action ensures that the healthcare provider can maintain crucial vascular access without introducing further problematic blood products.

Immediate Steps Following a Transfusion Reaction

• Stop the transfusion immediately.
• Keep the vein open with normal saline.
• Check the blood product and patient's identification to confirm that the correct blood was given.
• Monitor vital signs closely.
• Notify the physician for further orders.

Following these immediate nursing interventions, additional actions such as administering medications, drawing blood samples for testing, and performing further assessments are carried out under physician orders or institutional protocols.

NCLEX-RN Exam Preparation

Preparation for the NCLEX-RN exam, particularly concerning blood transfusion reactions, requires a deep understanding of nursing interventions and prioritizing patient care. Questions relating to transfusion reactions are common on the exam because they test the nurse's ability to identify critical changes in a patient's condition, prioritize interventions, and implement appropriate actions efficiently.

Students preparing for the NCLEX-RN must familiarize themselves with the signs and symptoms of transfusion reactions and the immediate nursing interventions. Mastery of these concepts is not only vital for passing the exam but also for safe clinical practice.

Key NCLEX-RN Concepts for Transfusion Reactions

• Recognizing symptoms of a transfusion reaction.
• Understanding the appropriate nursing interventions.
• Identifying actions that must be taken immediately versus those which can follow.
• Knowing the importance of maintaining vascular access during an emergency.
• Applying patient care protocols accurately under pressure.

Exam preparation includes practicing sample questions, reviewing case studies, and participating in simulation labs to build confidence in responding quickly and correctly in critical situations.

Patient Care Protocols

Patient care protocols for blood transfusion reactions are standardized procedures that guide nurses and other healthcare professionals in the management of this critical event. They aim to provide a systematic response to ensure immediate and effective treatment, thus minimizing potential complications.

Protocols typically outline key steps to take, from the initial identification of a reaction to the post-reaction care and documentation. They also emphasize the importance of monitoring for symptoms of a reaction throughout the transfusion process, as early recognition leads to a more favorable patient outcome.

Essential Elements of Blood Transfusion Protocols

• Immediate cessation of the blood product infusion.
• Assessment of the patient’s condition with prompt reporting of any adverse symptoms.
• Keeping the line open with normal saline to maintain vascular access.
• Initiation of emergency interventions as needed such as the administration of antihistamines, corticosteroids, or vasopressors based on symptom severity.
• Comprehensive documentation of the incident, patient's response, and care provided.

Each healthcare facility will have its own set of detailed protocols, which are developed based on national guidelines and best practice recommendations. Nurses must be thoroughly familiar with these protocols and be able to execute them competently.