Difficulty: Medium
Average Score: 86%
Simulated
A nurse is assisting with the care of a client who is receiving a unit of packed red blood cells. Which of the following findings should indicate to the nurse that the client is experiencing a transfusion reaction?
Correct answer
A
Rationale
Temperature 38.8°C (101.8°F): A fever during transfusion is a classic sign of a transfusion reaction, such as a febrile non-hemolytic reaction. Generated rationale: A rise in temperature during a blood transfusion often indicates an immune response to the transfused blood, requiring immediate cessation of the transfusion and further evaluation.