The nurse is caring for an 80-year-old client who is receiving a unit of whole blood. The nurse understands that he must monitor this client for:
1. Fluid overload.
2. Infection.
3. Liver failure.
4. Thrombosis.
Fluid overload.
Rationale: High-risk clients for fluid overload are the elderly and those individuals who already have increased circulatory volume or who have a history of heart failure. Whole blood contains the most volume, and therefore it has the highest risk of fluid overload. The clinical manifestations of bacterial contamination may not occur until the transfusion is complete, or in some instances several hours later, depending on the virulence of the infecting organism. Liver failure is not associated with blood transfusions. Increased risk for thrombosis is not associated with blood transfusions.
You might also like to view...
The nurse is caring for a 10-year-old girl who is in an isolation room. Which of the following interventions would be a priority intervention for this child?
A) Reduce noise as much as possible. B) Provide age-appropriate toys and games. C) Discourage visits from family members. D) Put on mask prior to entering the room.
The nursing plan of care for a patient in pain should include which strategy?
A) Administer pain medication when the patient reports pain of at least a level of 4 out of 10. B) Administer pain medications around the clock. C) Administer pain medication when the nurse perceives the patient to be in pain. D) Administer pain medication only when patient states a need for pain relief.
Vaccines may generally be administered in the presence of:
a. current antimicrobial therapy. b. immunosuppression with neutropenia. c. acute severe illness and fever. d. previous allergic reactions to vaccines.
Nursing diagnoses and medical diagnoses are the same
Indicate whether the statement is true or false