The nurse enters a client's room to check the client who began receiving a blood transfusion 45 minutes earlier. The client is dyspneic and has a bounding pulse
The nurse listens to the client's lung sounds and notes the presence of crackles in the lung bases. The nurse determines that this client is most likely experiencing which of the following complications of blood transfusion therapy? 1. Bacteremia
2. Fluid overload
3. Hypervolemic shock
4. Allergic transfusion reaction
2
Rationale: With fluid overload, the client has the presence of crackles in the lungs in addition to dyspnea. Other clinical manifestations include hypertension, a bounding pulse, distended jugular veins, restlessness, and confusion. "Bacteremia," "hypervolemic shock," and "allergic transfusion reaction" are not associated with the manifestations noted in the question.
You might also like to view...
A piggyback of KCL 15 mEq in 250 mL of 0.9% saline is prescribed to be infused over 1 hour to treat a patient's hypokalemia. Which action is the most important before the infusion is started?
a. Assess the IV cannula and site to make sure the cannula is securely taped. b. Obtain an ECG monitor to monitor heart rhythm during the infusion. c. Review the previous 24-hour intake and output. d. Prepare an ice pack to place over the IV site to relieve the burning.
The school nurse is explaining to older school children that obesity increases the risk for which disorders? (Select all that apply.)
a. Asthma b. Hypertension c. Dyslipidemia d. Irritable bowel disease e. Altered glucose metabolism
A married couple is attending a hospital program about in vitro fertilization. During the program, a crew from a local television station arrives to film the proceedings because the station is publicizing a series on hospital services. The nurse conducting the program should:
A. Allow the television crew to videotape the program B. Explain to the television crew that videotaping is not allowed C. Ask the television crew to interview the individuals attending the program individually D. Allow the television crew to videotape the program as long as they do not publicize that the program is about in vitro fertilization
The nurse is assessing an older patient with Parkinson's disease who was started on entacapone 1 week ago. The patient has a history of coronary artery disease and takes an antihypertensive and aspirin
Which information would support the need for a reduction in medication dosage by the health care provider? a. Constipation b. Brownish orange urine c. Drowsiness d. Dizziness