When differentiating a client's adverse reaction to a blood transfusion, a nurse evaluates an anaphylactic response by the presence of:

Question

A. Wheezing and chest pain
B. Headache and muscle pain
C. Hypotension and tingling of the extremities
D. Crackles in the lungs and increased central venous pressure

Answer 1

A
A. Observe the client for wheezing, chest pain, and possible cardiac arrest. These are all indications of an anaphylactic reaction.
B. Be alert to client complaints of headache or muscle pain in the presence of a fever. Both may be indicative of a febrile nonhemolytic reaction.
C. In clients receiving massive transfusions, observe client for mild hypothermia, cardiac dysrhythmias, hypotension, and hypocalcemia. Cold blood products can affect the cardiac conduction system, resulting in ventricular dysrhythmias. Other cardiac dysrhythmias, hypotension, and tingling may indicate hypocalcemia, which occurs when citrate (used as a preservative for some blood products) combines with client's calcium.
D. Crackles in bases of lungs and a rising central venous pressure (CVP) are indications of circulatory overload.