Difficulty: Medium
Average Score: 90%
Simulated
A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?
Correct answer
C
Rationale
Vomiting is a sign of a septic reaction due to contaminated blood; distended veins suggest fluid overload, polyuria isn't typical, and hypertension isn't specific.