NCLEX Critical Care Nurse Question

NCLEX Critical Care Nurse Question


A client receiving a transfusion of packed red blood cells begins to vomit. The client's blood pressure is
90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8 ° F orally from a
baseline of 99.2 ° F. The nurse determines that the client may be experiencing which complication of a
blood transfusion?



A. Septicemia

B. Hyperkalemia

C. Circulatory overload

D. Delayed transfusion reaction - A. Septicemia



occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever,
vomiting, diarrhea, hypotension, and the development of shock.



2. The critical care nurse recognizes that an ideal plan for caregiver involvement includes



A. allowing caregivers at the bedside at preset, brief intervals.



B. a caregiver at the bedside at all times.



C. restriction of visiting in the ICU because the environment is overwhelming to caregivers.



D. an individually devised plan to involve caregivers with care and comfort measures. - D. An
individually devised plan to involve caregivers with care and comfort measures.



Rationale: An individualized plan of care should be developed for each patient and the caregivers.
Caregivers should be allowed to assist with care and comfort measures in the ICU if desired.