Question

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse plan to take if an allergic transfusion reaction is suspected? (Select all that apply.)

A. Stop the transfusion.
B. Monitor for hypertension.
C. Maintain an IV infusion with 0.9% NaCL
D. Position the client in an upright position with the feet lower than the heart
E. Administer diphenhydramine

Answer 1

In case of an allergic transfusion reaction, the nurse should stop the transfusion, maintain an IV with 0.9% NaCl, ensure the client is comfortable and safe, administer diphenhydramine, and monitor for hypotension.

Step-by-step explanation:

If a nurse suspects an allergic transfusion reaction while caring for a client receiving a blood transfusion, there are several critical actions that should be immediately taken:

1. Stop the transfusion immediately to prevent further exposure to the potentially harmful blood product.
2. Maintain an IV infusion with 0.9% NaCl to keep the vein open and allow for administration of medications or fluids as needed.
3. Position the client in a way that ensures safety and comfort. While the upright position with feet lower than the heart is sometimes recommended for shock, this is not universally required in allergic reactions. Instead, ensuring that the patient is in a safe and comfortable position is essential.
4. Administer diphenhydramine, an antihistamine, which can help alleviate some allergic symptoms such as itching and hives.
5. Monitor for hypotension, not hypertension, as low blood pressure is a marker of anaphylaxis and allergic reactions.

Note that while epinephrine is not listed in the original options provided, it is often used to treat severe life-threatening reactions (anaphylaxis).