Ace the PN Adult Medical Surgical Exam 2025 – Conquer the Clinical Challenge!

In a patient receiving blood transfusions, it is crucial for the nurse to closely monitor for signs of transfusion reactions due to the potential for serious complications. Transfusion reactions can range from mild allergic responses to severe, life-threatening conditions such as hemolytic reactions or anaphylaxis.

Signs of transfusion reactions may include fever, chills, rash, itching, dyspnea, or changes in vital signs—particularly an increase in heart rate or a decrease in blood pressure. Timely identification of these reactions allows for prompt intervention, which can significantly mitigate risks to the patient’s health.

While monitoring electrolyte levels is important for overall patient health, it is not the primary focus during transfusions unless the patient has known pre-existing conditions that may complicate electrolyte balance. Monitoring fluid intake is necessary for managing overall fluid status but does not specifically pertain to the transfusion process. Temperature fluctuations can be a sign of reactions, but they must be considered in the broader context of multiple signs and symptoms rather than isolated. Hence, the priority is on watching for any signs of transfusion reactions to ensure the patient's safety throughout the procedure.