The nurse has chosen the nursing diagnosis Risk of Injury for a patient who will likely need several blood transfusions to treat gastrointestinal bleeding
What rationale would the nurse provide for this choice? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. There is a risk of dehydration.
2. The patient has a risk of iron overload.
3. There is risk of hemolysis of red blood cells.
4. There is a risk for social isolation.
5. There is a risk for hearing loss.
2,3
Rationale 1: The patient receiving blood transfusions may experience fluid overload if fluid is given too quickly or from the physiologic action of the blood on interstitial fluids.
Rationale 2: Iron overload can occur if a patient chronically requires blood transfusions, as in the case of gastrointestinal bleeding, until the source of bleeding is identified and the bleeding is stopped.
Rationale 3: Transfusion reactions are a verified risk for this patient. Hemolytic transfusion reactions result in destruction of red blood cells.
Rationale 4: There is no reason a patient receiving blood transfusions should be isolated.
Rationale 5: Hearing loss is not a complication of blood transfusions.
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