The nurse is preparing to administer blood to a client with anemia. Which signs and symptoms of transfusion reaction should the nurse monitor for during the first 30 minutes? Select all that apply.
The client has a respiratory rate of 18 breaths/minute.
The client’s blood pressure increases from 104/56 to 164/92.
The client has an oxygen saturation level of 97% on 2L of oxygen.
The client becomes restless and confused with distended jugular veins.
The client complains of low back pain and a sense of impending doom.
Numbers 2, 4, and 5 are correct.
The respiratory rate is within normal limits. Hypertension indicates circulatory overload, which can occur when blood products are administered too quickly. The oxygen saturation level is within normal limits. Other signs of circulatory overload include restlessness, confusion, and distended jugular veins. Low back pain and a sense of impending doom indicate a hemolytic transfusion reaction caused by blood type or Rh incompatibility.
