Question

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?

A.Administer an antihistamine.
B.Slow the infusion rate.
C.Give the client a corticosteroid.
D.Elevate the client's lower extremities.

Answer 1

The nurse should administer an antihistamine, slow the infusion rate, and elevate the client's lower extremities to address the symptoms of restlessness, dyspnea, and crackles noted in the lung bases during a blood transfusion.

Step-by-step explanation:

Based on the symptoms described, the client is experiencing a transfusion reaction, specifically a hemolytic transfusion reaction. This occurs when the recipient's immune system reacts to the transfused blood, leading to destruction of red blood cells (RBCs) and release of substances that cause inflammation. The symptoms of restlessness, dyspnea, and crackles in the lung bases indicate an allergic response and lung involvement.

To address these symptoms, the nurse should:

1. Administer an antihistamine: Antihistamines help relieve allergic symptoms, such as dyspnea and rash, by blocking the effects of histamine, a substance released during an allergic reaction.
2. Slow the infusion rate: Slowing down the blood transfusion rate can help reduce the severity of the reaction and allow time to assess the client's condition.
3. Elevate the client's lower extremities: Elevating the client's lower extremities can help improve blood flow and reduce swelling.