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.
Administer diphenhydramine.
Obtain vital signs.
Notify the registered nurse.
The Correct Answer is A
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.
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Correct Answer is D
Explanation
A. Malformed RBCs: Malformed RBCs are not caused by a transfusion reaction; they are generally a result of bone marrow abnormalities or genetic conditions.
B. A deficiency in vitamin B12: Vitamin B12 deficiency causes megaloblastic anemia, not hemolysis. It is unrelated to transfusion reactions.
C. An abundance of immature RBCs: Immature RBCs, or reticulocytes, can increase as a compensatory response to anemia but are not a direct result of a transfusion reaction. The primary issue is RBC destruction.
D. Destruction of RBCs: A hemolytic reaction occurs when the immune system attacks incompatible red blood cells, leading to their destruction.
Correct Answer is D
Explanation
A. Hematocrit 35% (F 37%–47%; M 42%–52%): Although the hematocrit is slightly low, it is not as concerning as a low platelet count, which poses an immediate risk for bleeding.
B. Bone pain: Bone pain is common in leukemia due to bone marrow expansion, but it does not take priority over the risk of bleeding from thrombocytopenia.
C. Weight loss: Weight loss may be a symptom of leukemia, but it is not immediately life-threatening and does not take priority over a low platelet count that increases bleeding risk.
D. Platelet count 125,000/mm³ (150,000–400,000): A low platelet count is concerning in leukemia patients because it increases the risk of bleeding. Monitoring for and preventing bleeding is a high priority due to thrombocytopenia associated with leukemia.