A child is receiving a blood transfusion. On assessment, the ...

[Mr. Wonderful]

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 2

The pediatric nurse is aware that the most common type of transfusion reaction is which of the following?
 
  A.
  Acute hemolytic reaction
  B.
  Allergic reaction
  C.
  Circulatory overload
  D.
  Febrile reaction

[Viet Thy]

Answer to Question 1

ANS: B
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.

Answer to Question 2

ANS: D
The febrile reaction is the most common type of transfusion reaction and can occur up to 12 hours post-transfusion.