Question

A nurse is caring for a client who is receiving a transfusion of packed red blood cells (RBCs).

Exhbit 1
Vital Signs
0900:
Temperature 36.9° C (98.5° F)Heart rate 74/minRespiratory rate 16/minBlood pressure 112/68 mm HgPulse oximetry 98%
0915:
Temperature 36.9° C (98.5° F)Heart rate 76/minRespiratory rate 16/minBlood pressure 120/68 mm HgPulse oximetry 98%
0930:
Temperature 36.9° C (98.5° F)Heart rate 80/minRespiratory rate 18/minBlood pressure 116/70 mm HgPulse oximetry 98%

Exhibit 2
Diagnostic Results
0800:
Hgb 5.6 g/dL (12 to 16 g/dL)Platelet count 18,000/mm3 (150,000 to 400,00/mm3)

Exhibit 3
Nurses' Notes
0900:
Platelet count and Hgb unchanged from post-transfusion results yesterday. Infusion of 1 unit of packed RBCs started as ordered.Client alert and oriented to person, place, and time.
0930:
Client requests pain medication for headache and reports pain level of 5 on a scale from 0 to 10. Client reports ""arthritis must be acting up because my back and knees and ankles hurt."" Asked if nurse can assist in placing pillows behind back for low back pain. Reports back and joint pain as 4 on a scale of 0 to 10.States they did not have any concerns yesterday during transfusions but ""starting to feel a little anxious about it now. I'm not really sure why I need this."" Alert and oriented to person and place.Skin pale, cool, and dry to touch. Mucous membranes pink and moist.Urine output 150 mL of clear, yellow urine in urinal.

The nurse should suspect a transfusion reaction based on which of the following assessment findings?
Select all that apply.

A. Urine output
B. Anxiety
C. Headache
D. Back pain
E. Skin
F. Vital signs

Answer 1

The nurse should suspect a transfusion reaction based on the client's anxiety, headache, back pain, pale skin, and changes in vital signs.

Step-by-step explanation:

Based on the assessment findings, the nurse should suspect a transfusion reaction based on the following:
- Anxiety: The client reports feeling anxious about the transfusion, which can be a sign of a reaction.
- Headache: The client requests pain medication for a headache, which can be a symptom of a transfusion reaction.
- Back pain: The client reports back and joint pain, which can also be a symptom of a transfusion reaction.
- Skin: The client's skin is pale, cool, and dry to the touch, which can indicate a reaction.
- Vital signs: Although the vital signs are within normal range, the increasing heart rate and changes in blood pressure can be signs of a reaction.