Blood Transfusion Reactions And Immediate Actions - NCLEX Rn

Which respiratory findings suggest transfusion-related acute lung injury (TRALI)?

Acute hypoxemia with dyspnea and pulmonary edema signs. TRALI involves donor antibodies causing noncardiogenic pulmonary edema and respiratory failure.
Which timing rule is essential for early detection of transfusion reactions after initiation?

Remain with patient and monitor closely for the first 15 minutes. Most severe reactions occur early due to initial antigen exposure, enabling prompt intervention.
Which action is required when septic transfusion reaction is suspected?

Stop transfusion and obtain ordered blood cultures promptly. Stopping prevents further bacterial load, and cultures identify the pathogen for targeted antibiotics.
Which urine finding is most consistent with an acute hemolytic transfusion reaction?

Hemoglobinuria (dark or red-brown urine). Free hemoglobin from lysed RBCs is excreted in urine, signaling acute hemolysis.
Which medication is commonly prescribed for a mild allergic transfusion reaction?

Antihistamine (e.g., diphenhydramine) as prescribed. It blocks histamine receptors, alleviating allergic symptoms like itching and hives.
Which action is required to prevent further exposure when a transfusion reaction is suspected?

Disconnect blood tubing; do not flush blood into the patient. Disconnecting without flushing avoids infusing residual incompatible blood, reducing further hemolysis or antigen exposure.
What should the nurse do with the blood bag and tubing after a suspected transfusion reaction?

Send blood bag and tubing to the blood bank per policy. Returning them allows lab analysis to identify the reaction cause, such as incompatibility or contamination.
Which emergency medication is first-line for transfusion-associated anaphylaxis?

Epinephrine per emergency protocol/prescription. As an adrenergic agonist, it reverses bronchospasm and hypotension in anaphylaxis.
Which IV fluid should be used to keep the vein open after stopping a suspected transfusion reaction?

0.9% sodium chloride (normal saline) with new tubing. Normal saline is compatible with blood products and maintains IV patency without causing hemolysis, while new tubing prevents contamination.
Which symptom most strongly suggests an acute hemolytic transfusion reaction?

Back or flank pain with fever and hypotension. These indicate intravascular hemolysis from ABO incompatibility, causing renal pain and systemic effects.
Which findings are most consistent with a mild allergic transfusion reaction?

Urticaria, pruritus, and flushing without respiratory distress. These reflect histamine release from IgE-mediated response to plasma proteins, without systemic involvement.
Which symptom pattern most strongly indicates a febrile nonhemolytic transfusion reaction?

Fever and chills without hypotension or hemoglobinuria. Caused by leukocyte antibodies, it presents as an immune response without hemolysis or circulatory instability.
What documentation is essential immediately after a suspected transfusion reaction?

Symptoms, vital signs, time started/stopped, and interventions. Accurate records support diagnosis, guide treatment, and meet legal requirements for transfusion incidents.
Which medication is commonly prescribed for a febrile nonhemolytic transfusion reaction?

Acetaminophen as prescribed. It reduces fever by inhibiting prostaglandin synthesis in the hypothalamus.
What is the nurse's first action when a transfusion reaction is suspected during infusion?

Stop the transfusion immediately. Halting the infusion prevents further administration of potentially incompatible blood, minimizing the severity of the reaction.
Which bedside check must be verified before starting any blood transfusion to prevent ABO error?

Two-person verification of patient ID and blood product label. Dual verification reduces clerical errors that could lead to ABO incompatibility and hemolytic reactions.
Which lab specimen is typically obtained from the patient after a suspected hemolytic transfusion reaction?

Postreaction blood sample for hemolysis workup per policy. It allows comparison to prereaction levels to confirm hemolysis via markers like LDH and bilirubin.
Which findings most strongly suggest transfusion-associated circulatory overload (TACO)?

Dyspnea, hypertension, crackles, and jugular venous distention. These indicate fluid overload leading to cardiogenic pulmonary edema in at-risk patients.
Which findings most strongly indicate anaphylaxis from transfusion?

Hypotension, wheezing/stridor, angioedema, and shock. These signify severe IgA deficiency or allergy leading to systemic anaphylactic response.
What is the priority assessment to perform immediately after stopping a suspected transfusion reaction?

Assess airway, breathing, circulation, and vital signs. Evaluating ABCs and vital signs identifies life-threatening complications like shock or respiratory distress promptly.
Which provider notification is required after initiating reaction protocol for a transfusion reaction?

Notify the health care provider and the blood bank immediately. Immediate notification ensures prompt medical intervention and blood bank investigation to confirm the reaction type.
Which intervention is commonly anticipated for suspected TACO?

Upright positioning, oxygen, and diuretics as prescribed. These measures reduce preload and improve oxygenation in volume overload.
Which immediate supportive action is anticipated for suspected TRALI?

Provide oxygen and supportive respiratory care. Oxygenation and ventilation support address hypoxemia while the condition resolves.
Which finding most strongly indicates bacterial contamination or septic transfusion reaction?

High fever with rigors and hypotension during transfusion. Bacterial endotoxins cause rapid sepsis-like symptoms during infusion.
Which intervention is commonly anticipated to protect renal function in acute hemolytic reaction?

Maintain IV fluids; anticipate diuretics as prescribed. Hydration and diuresis promote renal clearance of hemoglobin, preventing acute kidney injury from tubular obstruction.

Study these flashcards