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NCLEX Question of the Day
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The nurse is monitoring a client receiving packed red blood cells (PRBCs). Fifteen minutes into the infusion, the client reports feeling flushed, itchy, and short of breath. The nurse notes hives on the client's chest. What is the nurse's immediate priority action?
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Correct answer Stop the blood transfusion immediately.
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Slow the infusion rate.
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Administer prescribed diphenhydramine.
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Check the client's vital signs.
Rationale
The client's symptoms (flushing, itching/urticaria, shortness of breath) are indicative of an acute transfusion reaction, likely allergic or anaphylactic. The immediate priority action is to stop the transfusion to prevent further infusion of the substance causing the reaction. This minimizes the severity of the reaction.
While administering diphenhydramine (an antihistamine) may be prescribed to treat the symptoms, it is not the first action; stopping the offending agent is paramount. Checking vital signs is crucial for assessment but should be done immediately after stopping the infusion. Slowing the infusion rate is inappropriate as any amount of continued infusion could worsen the reaction.
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