Difficulty: Medium
Average Score: 91%
Simulated
Passage / Scenario
Nurse's NotesClient admitted to the unit for a lower GI bleed. Continues to have frequent bloody stools and is scheduled for a lower endoscopy in 4 hr. The client is receiving their fourth unit of packed red blood cells (packed RBCs). Unit of fourth packed RBCS started at a rate of 250 cc/hr. Thirty minutes after the transfusion started, client started reporting dyspnea and restlessness. Crackles auscultated in bilateral lower lobes. oxygen saturation 92% on 2L nasal cannula, and jugular vein distension noted.
Vital Signs
Temperature 37.3" (99.1" F)
Blood pressure 189/90 mm Hg
Pulse rate 100/min
Respiratory rate 28/min
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Correct answer
B,C
Rationale
The client's symptoms are consistent with TACO. Administer furosemide to reduce fluid overload and diphenhydramine for possible mild allergic reaction. Monitor intake and output and weight to assess fluid balance.