Author Question: A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing ... (Read 29 times)

nenivikky · **on:** Jul 22, 2018

A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse's next action?

a. Discontinue the IV catheter.
b. Return the blood to the blood bank.
c. Run normal saline through the existing tubing.
d. Start normal saline at TKO rate using new tubing.

Question 2

A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic.

The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions?
a. Fluid volume overload
b. Hemolytic reaction
c. Anaphylactic shock
d. Septicemia

sierramartinez · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: D
The nurse should first attach new tubing and begin running in normal saline at a rate to keep the vein open, in case any medications need to be delivered through an IV site. The existing tubing should not be used because that would infuse the blood in the tubing into the patient. It is necessary to preserve the IV catheter in place for IV access to treat the patient. After the patient has been assessed and stabilized, the blood can be returned to the blood bank.

Answer to Question 2

ANS: A
The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic reaction would consist of flank pain, chills, and fever.