Nokea
Nurse's Notes:
Client admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. 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 cc/hr. Thirty minutes after the transfusion started, the client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes. oxygen saturation 92% on 2L nasal cannula, and jugular vein distention noted.
Vital signs:
Temperature: 37.0°C (98.6°F)
Heart Rate (HR): 110 beats per minute
Blood Pressure (BP): 150/90 mmHg
Respiratory Rate (RR): 24 breaths per minute
Oxygen Saturation (SpO2): 92% on 2L nasal cannula
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.
Correct Answer: B,C,D
Rationale: The client is experiencing transfusion-associated circulatory overload (TACO), indicated by dyspnea, crackles, jugular vein distention, and hypertension. Stopping the transfusion prevents further fluid overload, and furosemide removes excess fluid. Monitoring weight and respiratory rate assesses fluid status and respiratory distress.