The nurse is caring for an 80-year-old patient who is receiving a unit of whole blood. During the transfusion the nurse prioritizes assessment for which possible complication?
1. Liver failure
2. Infection
3. Fluid overload
4. Thrombosis
3
Rationale 1: Liver failure is not associated with blood transfusions.
Rationale 2: 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. This is not the most critical assessment during the transfusion.
Rationale 3: Older patients are at high risk for fluid volume overload during blood transfusions. Whole blood has the most volume, so it also carries the highest risk of causing fluid overload.
Rationale 4: An increased risk for thrombosis is not common during blood transfusion.
You might also like to view...
A patient with traumatic brain injury is experiencing cerebral edema, which has led to severely elevated intracranial pressure. He has increased pulse pressure, decreased heart rate, and an irregular respiratory pattern
He has lost consciousness and demonstrates bilateral pupillary dilation. The nurse recognizes that these symptoms point to which condition? A) Central herniation syndrome B) Uncal herniation syndrome C) Cerebrovascular injury D) Diffuse axonal injury
The patient has experienced an accidental salicylate overdose. Urine alkalinization with intravenous sodium bicarbonate solution is ordered. What symptom, if found by the nurse, most indicates a complication of this therapy?
A) Increased urine pH B) Increased urine salicylate levels C) Compensated metabolic alkalosis D) Altered level of consciousness
What are benefits of dehydration for a person who is near death? (Select all that apply.)
a. Better gas exchange because of reduction of fluid in the lungs b. Decreased need to suction because of reduction of respiratory secretions c. Improved bowel elimination because of reduced bulk in the stool d. Decreased pain related to release of endorphins e. Improved drug distribution via the circulating volume
Your 68-year-old client needs balanced suspended traction for a fracture of the right femur with a stage II pressure ulcer measuring 2×3 cm on the left buttock. Which of the following nursing diagnoses would be most appropriate for the pressure ulcer?
1. Impaired tissue integrity 2. Body image disturbance 3. Hopelessness 4. Impaired skin integrity