An older adult patient is receiving a transfusion of packed red blood cells after being injured in a car accident. On assessment, the nurse notes a new finding of bounding pulse, crackles, and increasing dyspnea
What should the nurse do first, after stopping the transfusion?
a. Administer prn diphenhydramine (Benadryl) as ordered.
b. Raise the head of the bed.
c. Assess vital signs.
d. Encourage the patient to deep breathe and cough.
ANS: B
Elderly patients have less cardiac and renal ability to adapt to changes in blood volume, so they have a much higher risk of fluid overload when receiving blood transfusions. New onset of dyspnea, crackles, hypertension, or bounding pulse should be reported to the registered nurse or physician immediately. Raising the head of the bed will help ease breathing. Diphenhydramine is helpful for allergic reactions. C and D may be helpful, but the first priority is positioning the patient to breathe more easily.
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