A client began receiving a unit of blood ~5 minutes ago and states that he is "terribly itchy." The client's face is visibly flushed and there is a rash on his upper chest. However, his vital signs are within normal limits
What should the nurse do in response to this? A) Stop the blood infusion and administer a bolus of normal saline
B) Increase the rate of infusion to overcome the client's temporary response
C) Slow the infusion rate and prepare an antihistamine
D) Stop the infusion and administer an antiemetic
C
Feedback:
The client's signs and symptoms are characteristic of an allergic reaction, which should prompt the nurse to slow the rate and possibly administer an antihistamine. It would be inappropriate to increase the rate of infusion or to administer an antiemetic. It is not normally necessary to stop the infusion.
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