Difficulty: Medium
Average Score: 74%
Simulated
A nurse is educating a student nurse about blood transfusions. Which of the following statements by the student nurse indicates the need for additional teaching? Select all that apply.
Correct answer
A,E
Rationale
Crackles in the lung fields indicate transfusion-associated circulatory overload (TACO), not a hemolytic reaction, which typically presents with fever, chills, and hemoglobinuria. Pre-medication with diphenhydramine and acetaminophen is not always required, only when prescribed for clients with a history of allergic reactions. The other statements are correct: graft versus host disease is common in immunosuppressed clients, TACO is more likely in renal failure, and transfusion history is important.