A nurse is reviewing the baseline assessment and history of a client. Based on the assessment findings of lungs clear to auscultation, temperature 98.2 F, blood pressure 132/80, pulse 92, and respirations 20, which of the following would be an expected finding?

Choice A rationale An acute hemolytic reaction is a life threatening complication of blood transfusions caused by ABO incompatibility. Clinical manifestations typically include fever, chills, hypotension, tachycardia, and excruciating lower back pain. The assessment findings provided show a normal temperature of 98.2 F and a stable blood pressure of 132/80, which are inconsistent with the systemic inflammatory response and vascular collapse seen in hemolysis. Therefore, a hemolytic reaction would not be an expected finding based on these stable baseline vital signs. Choice B rationale Shortness of breath and crackles in the lungs are primary indicators of fluid volume overload or pulmonary edema. The baseline assessment explicitly states that the lungs are clear to auscultation and the respiratory rate is within the normal range of 12 to 20 breaths per minute at 20. If a client were experiencing circulatory overload, the nurse would expect to hear adventitious breath sounds and observe an increased work of breathing, neither of which is present in the current clinical data. Choice C rationale An increase in hemoglobin and hematocrit is the physiological goal of a red blood cell transfusion. Red blood cells are administered to improve oxygen carrying capacity in patients with anemia or acute blood loss. Normal hemoglobin ranges are 14 to 18 g/dL for men and 12 to 16 g/dL for women, while hematocrit ranges from 42 percent to 52 percent for men and 37 percent to 47 percent for women. These values should rise proportionately following a successful and uncomplicated transfusion. Choice D rationale A decrease in platelet count, known as thrombocytopenia, is not a typical or expected outcome of a standard red blood cell transfusion. Platelets are responsible for primary hemostasis and a normal count ranges from 150,000 to 400,000 cells/mm. While some dilutional effects can occur during massive transfusion protocols, a routine unit of packed red blood cells should not cause a drop in platelet levels. Such a finding might instead suggest an underlying pathology like disseminated intravascular coagulation or heparin induced thrombocytopenia.