A child is receiving a blood transfusion.On assessment,the nurse finds the child short of breath,febrile,and hypotensive.After stopping the transfusion,what action by the nurse takes priority?
A) Document the findings.
B) Obtain oxygen saturation.
C) Prepare fluid resuscitation.
D) Sit the child upright in bed.

Question

Quizplus · Accepted Answer

The manifestations can be related to several different types of transfusion reactions,but hypoxia is most closely associated with transfusion-related lung injury (TRALI).The nurse obtains an oxygen saturation.Documentation must be completed,but this is not the priority.It is unknown at this time if the child needs aggressive fluid resuscitation or blood pressure support.Sitting the child upright may help breathing,but will worsen the hypotension.

A Child Is Receiving a Blood Transfusion