Question

A nurse is caring for a client who is receiving a unit of packed RBCs.

Nurses' Notes:
0800: Packed RBCs initiated by the charge nurse through an 18-guage peripheral IV to infuse over 2 hr.
0815: Client reports itching and anxiety. Client's face is flushed and has hives.
Complete the following sentence by using the list of options.
The client has manifestations of, as evidenced by the client's
a) Flushed face and hives
b) Elevated blood pressure and nausea
c) Cool extremities and confusion
d) Bradycardia and wheezing

Answer 1

The client's symptoms of itching, anxiety, flushed face, and hives after starting a blood transfusion indicate an allergic or transfusion reaction. Immediate action is necessary, and the protocol for a suspected transfusion reaction should be followed.

Step-by-step explanation:

Clinical Signs of a Transfusion Reaction

The client has manifestations of an allergic reaction or transfusion reaction, as evidenced by the client's flushed face and hives. These symptoms, including itching and anxiety, are consistent with a hypersensitivity reaction to the transfused packed red blood cells (RBCs). Immediate action is required to manage the reaction and prevent more severe complications such as anaphylaxis. The nurse should stop the transfusion and follow the facility's protocol for a suspected transfusion reaction which generally includes keeping the IV line open with saline, notifying the physician, monitoring the patient's vital signs, and collecting blood samples for investigation.