RN Adult Med Surg Practice NCLEX

RN Adult Med Surg Practice NCLEX 2023- 2024 What are the findings for acute hemolytic transfusion reaction and time of onset? - ANSWER-chills, fever, low-back pain, tachycardia, flushing, hypotension, chest tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and impending sense of doom. Immediate or can manifest during subsequent infusions. What are the nursing actions for hemolytic transfusion reaction? - ANSWER-1. Stop transfusion 2. Remove blood from IV access. AVOID infusing further blood products. 3. Initiate an infusion of 0.9% sodium chloride using new tubing 4. monitory vital signs and fluid status 5. Send the blood bag and admin set to lab for testing Nurse is preparing to administer packed RBCs to a client who has Hgb of 6 g/dL. Which is the next action to perform during the first 15 minutes of the transfusion? - ANSWER-Assess for hemolytic transfusion reaction When can a febrile transfusion reaction happen after a client received blood products? - ANSWERCommonly occurs 2 hr after Name the findings of febrile transfusion reaction - ANSWER-Anti-WBC antibodies, chills (increase of 1·C (2·F) or greater from pretransfusion temp, flushing, hypotension, tachycardia A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? - ANSWER-Heart rate change from 88/min to 120/min. Client appears flushed When can an "allergic" transfusion reaction happen? - ANSWER-During or up to 24 hrs after What would the nurse notice when a client has allergic transfusion reaction to blood products? - ANSWER-Mild itching, urticaria, flushing What nursing actions are performed for mild "allergic" reaction to blood products? - ANSWERStop the transfusion Maintain IV infusion w/ 0.9% sodium chloride Administer antihistamine (diphenhydramine) If provider prescribes to restart transfusion, proceed slowly What findings would the nurse expect to with circulatory overload during blood transfusion? - ANSWER-Crackles, dyspnea, cough, anxiety, jugular vein distention, tachycardia. Can progress to pulmonary edema.