A nurse is assessing an older adult client who is receiving 2 units of packed RBCs. Which of the following manifestations should indicate to the nurse that the client is experiencing circulatory overload?

Rationale:

A. Administer morphine 4 mg IV bolus: Morphine is appropriate for severe chest pain unrelieved by nitrates. It decreases preload, pain, and anxiety, reducing myocardial oxygen demand. This intervention helps improve comfort and may lower sympathetic nervous system activation during an acute MI.

B. Prepare client for an exercise tolerance test: This is contraindicated during active chest pain and elevated troponin levels. Stress testing would increase cardiac workload and worsen ischemia. It is only done when a patient is stable and MI has been ruled out.

C. Administer an intermittent IV fluid bolus: Fluid boluses are not indicated unless hypotension or hypovolemia is present. Extra fluid can increase cardiac workload and worsen outcomes in MI. In a normotensive patient with chest pain, it offers no benefit and may increase risk of pulmonary congestion.

D. Administer nitroglycerin sublingual: Nitroglycerin is a first-line medication for ischemic chest pain. It improves blood flow by dilating coronary arteries and reducing cardiac preload. It can rapidly relieve angina and should be administered as soon as possible in acute chest pain.

E. Place the client in the supine position: Supine positioning may worsen breathing difficulty and is not ideal during acute chest pain. A semi-Fowler's position is better to support oxygenation. Keeping the head elevated helps reduce venous return and cardiac workload.

F. Apply oxygen at 2 L/min via nasal cannula: Oxygen is appropriate with labored respirations and signs of hypoxia. It improves oxygen delivery to the myocardium during ischemic events. Supplemental oxygen can help stabilize oxygen saturation while definitive interventions are underway.

G. Prepare client for percutaneous coronary intervention: PCI is a key treatment for myocardial infarction and should be anticipated given the client’s chest pain, elevated troponin, and high risk profile. It restores perfusion to the affected coronary artery and reduces infarct size and mortality when performed promptly.

Rationale:

Stop transfusion: The client is showing signs of a serious transfusion reaction such as fever, chills, back pain, and hypotension. Immediately stopping the transfusion prevents further infusion of incompatible blood, which could worsen hemolysis and lead to shock or kidney failure.

Flush blood transfusion tubing: Flushing the existing blood tubing with saline could push more incompatible blood cells into the circulation. This can intensify the reaction and increase the risk of complications. Instead, new IV tubing with normal saline should be used if further IV access is needed.

Notify blood bank: The blood bank must be informed to initiate an investigation, verify blood compatibility, and conduct testing to determine the cause of the reaction. This helps prevent further occurrences and ensures patient safety.

Notify primary physician: The physician needs to be informed promptly to provide additional orders, such as fluid resuscitation, lab tests, or medications to stabilize the client. Immediate collaboration is essential to manage the adverse event effectively.

Return blood and tubing to blood bank: Returning the blood product and used tubing allows the blood bank to analyze the unit for errors or contamination. This is necessary for confirming the transfusion reaction and documenting the incident.

Administer IV diphenhydramine: Diphenhydramine may be used to reduce symptoms such as itching or chills if an allergic component is suspected. It is often part of the initial response while further evaluation and treatment are underway.

Administer oxygen: The client’s oxygen saturation has dropped, and respirations are rapid and labored. Administering oxygen supports tissue oxygenation and addresses hypoxia during this acute reaction, which may compromise respiratory function.