Question

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

(a) Slow the transfusion rate and administer oxygen.
(b) Stop the transfusion and notify the physician.
(c) Continue the transfusion and monitor vital signs.
(d) Increase the transfusion rate and administer fluids.

Answer 1

If a client receiving a blood transfusion becomes restless, dyspneic, and has crackles at the lung bases, the nurse should stop the transfusion, inform the physician, monitor vital signs, provide oxygen, and anticipate administration of diuretics.

Step-by-step explanation:

If a client becomes restless, dyspneic, and has crackles noted in the lung bases while receiving a blood transfusion, this may indicate the onset of a transfusion reaction such as transfusion-associated circulatory overload (TACO). The immediate actions for the nurse to anticipate taking in this situation would not be to increase the transfusion rate or administer more fluids. Doing so could exacerbate the situation. Instead, the nurse should:

• Stop the transfusion immediately.
• Inform the physician or emergency response team.
• Monitor vital signs and assess the patient for other symptoms.
• Provide oxygen if the patient is hypoxic.
• Position the patient upright with feet dependent to help reduce fluid overload in the lungs.
• Be prepared to administer diuretics as prescribed to alleviate fluid overload symptoms.

Blood transfusion reactions can be life-threatening, and prompt recognition and appropriate intervention are crucial.