Practice NGN Question: Blood Transfusion Reaction
Nurse's Notes
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools. The client is
receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCs started at
a rate of 250 mL/hr. Thirty minutes after the transfusion started, client started reporting dyspnea and
restlessness. Crackles auscultated in bilateral lower lobes, oxygen saturation 92% on 2L nasal cannula,
and jugular vein distension noted.
Vital Signs
Temperature 37.3° (99.1° F)
Blood pressure 189/90 mm Hg
Pulse rate 100/min
Respiratory rate 28/min
Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing, two actions the nurse should take to address that condition, and two parameters
the nurse should monitor to assess the client's progress.
Action #1 Parameter to
monitor
Condition most likely
Experiencing
Parameter to
Action #2 monitor
Nurse's Notes
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools. The client is
receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCs started at
a rate of 250 mL/hr. Thirty minutes after the transfusion started, client started reporting dyspnea and
restlessness. Crackles auscultated in bilateral lower lobes, oxygen saturation 92% on 2L nasal cannula,
and jugular vein distension noted.
Vital Signs
Temperature 37.3° (99.1° F)
Blood pressure 189/90 mm Hg
Pulse rate 100/min
Respiratory rate 28/min
Complete the diagram by dragging from the choices below to specify what condition the client is most
likely experiencing, two actions the nurse should take to address that condition, and two parameters
the nurse should monitor to assess the client's progress.
Action #1 Parameter to
monitor
Condition most likely
Experiencing
Parameter to
Action #2 monitor
