Question

Mrs. Sing, 69 years old, has been admitted with anemia. She has a history of chronic congestive heart failure. Two hours into her blood transfusion, Mrs. Schwartz develops a dry cough. What should the nurse do? a. Discontinue the transfusion, sit her upright, monitor vital signs closely, and report b. Continue the transfusion, assess her breathing, collect sputum for culture and sensitivity, and document c. Stop the transfusion, have her deep breathe and cough, check her oxygen saturation, and document d. Slow the rate of the blood transfusion, monitor vital signs, report, and document

Answer 1

a. Discontinue the transfusion, sit her upright, monitor vital signs closely, and report.

Step-by-step explanation:

Here's why:

1. Discontinuing the transfusion is a prudent step to prevent the reaction from worsening.

2. Sitting her upright can help improve her breathing and oxygenation.

3. Monitoring vital signs closely, including blood pressure, heart rate, and oxygen saturation, is essential to assess the severity of the reaction and the patient's overall condition.

4. Reporting the incident to the healthcare provider or the appropriate department is necessary for documentation, evaluation, and further guidance.

While options b, c, and d involve assessing and addressing various aspects of the situation, option a is the most appropriate initial action when a transfusion reaction is suspected. Once the patient's condition is stabilized, further assessment and evaluation can be performed as needed.