A rapid infusion of blood has been given to the client. The nurse assesses the client for which one of the following?
a. Diaphoresis
b. Anxiety
c. Hypertension and tachycardia
d. Nausea and vomiting
C
Hypertension and tachycardia are signs of circulatory overload from blood being administered faster than the circulation can accommodate. Other signs of overload are cough, dyspnea, pul-monary congestion (rales), headache, and distended neck veins.
The client who has a rapid blood transfusion of blood would not be expected to experience ex-cessive sweating.
Anxiety may be related to an anaphylactic or febrile, nonhemolytic reaction to a blood transfu-sion. However, it is not the best indication of a possible reaction as the client may be anxious because of receiving a blood transfusion, having nothing to do with a physiological reaction to the transfusion.
Nausea and vomiting may or may not indicate a reaction to a blood transfusion.
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