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    Ati med surg proctored examQuestion 56
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    Ati med surg proctored exam

    A nurse is caring for a male client on a medical-surgical unit. Exhibits Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The nurse suspects that the client has developed dropdownbased ondropdown.

    Explanation & Rationale

    Rationale for correct choices: • Transfusion-associated circulatory overload: Characterized by dyspnea, cough, crackles in the lungs, jugular vein distention, and hypertension due to fluid overload during transfusion. The client’s findings of shortness of breath, cough, crackles, and distended neck veins directly align with this condition. • Lung sounds: The presence of new crackles bilaterally along with dyspnea indicates fluid overload affecting pulmonary circulation, consistent with TACO. Rationale for incorrect choices: • Acute intravascular hemolytic reaction: This reaction presents with flank pain, fever, chills, and hemoglobinuria due to incompatible blood. The client shows no evidence of hematuria, fever spike, or severe back pain. • Anaphylactic reaction: Anaphylaxis occurs rapidly, with symptoms such as bronchospasm, hypotension, urticaria, and possible shock. The client does not have a rash, hives, or hypotension, which rules this out. • Febrile nonhemolytic reaction: Typically presents with fever, chills, and headache caused by donor WBCs. The client’s temperature is stable and no chills are reported, so this does not match. • Sepsis transfusion reaction: This occurs when contaminated blood is transfused, leading to fever, hypotension, and rigors. The client is not hypotensive or febrile, making this less likely. • Temperature: A temperature rise would point to a febrile or septic transfusion reaction, but the client’s temperature remained stable. • Urticaria: Urticaria would suggest an allergic or anaphylactic reaction, which was not observed. • Hypotension: Hypotension is seen with hemolytic or septic reactions, but this client’s blood pressure is elevated, not decreased. • Chills: Chills are typical of febrile or hemolytic reactions, but the client did not report them.

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