Question

Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first?

a.Administer oxygen
b.Notify the physician
c.Check for fluid overload
d.Document the findings

Answer 1

Administer oxygen to improve oxygenation and relieve respiratory distress. Notify the physician of the patient's deteriorating condition.

Step-by-step explanation:

In this case, the patient's symptoms suggest fluid overload, which can occur after a unit of packed red blood cells infusion. The tachycardia, bounding pulses, crackles, and wheezes are indicative of fluid in the lungs and increased fluid volume in the body. The first action the nurse should implement is to administer oxygen to improve oxygenation and relieve respiratory distress.

Administering oxygen helps to increase the oxygen levels in the blood and alleviate symptoms of hypoxemia. This is crucial in an acute situation like this where the patient is in respiratory distress.

After administering oxygen, the nurse should then notify the physician of the patient's deteriorating condition. The physician may need to order additional interventions such as diuretics or adjust fluid therapy to address the fluid overload.