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Difficulty: HardReduction of Risk Potential

A nurse is caring for an adult client who is receiving a massive blood transfusion protocol (6 units of packed red blood cells over the past 3 hours) due to severe gastrointestinal hemorrhage. The nurse assesses the client for potential physiological complications of the rapid, massive transfusion. Which of the following assessment findings require immediate intervention by the nurse? Select all that apply.

  1. Prolonged QT interval on the telemetry monitorAnswer
  2. New onset of bilateral basilar crackles and jugular venous distentionAnswer
  3. Tall, peaked T waves on the electrocardiogramAnswer
  4. D
    Oral temperature of 99.1°F (37.3°C)
  5. E
    Mean arterial pressure (MAP) increasing from 55 mm Hg to 72 mm Hg
  6. F
    Urine output averaging 40 mL/hour over the last 2 hours

Answer

The findings requiring immediate intervention are the prolonged QT interval, new onset of bilateral basilar crackles with jugular venous distention, and tall, peaked T waves.
Massive blood transfusions carry significant physiological risks. Banked blood contains citrate as an anticoagulant, which can rapidly bind to the client's serum calcium, leading to acute hypocalcemia (manifested by a prolonged QT interval). Furthermore, as stored red blood cells age, they hemolyze and leak intracellular potassium into the plasma; massive transfusions can consequently cause severe hyperkalemia (manifested by tall, peaked T waves). Additionally, the rapid intravenous infusion of large colloidal fluid volumes places the client at high risk for transfusion-associated circulatory overload (TACO), which presents with signs of fluid volume excess such as bibasilar crackles and jugular venous distention. All of these findings indicate potentially life-threatening complications that require immediate medical intervention.

Step-by-Step Solution

1
Analyze the clinical scenario and the therapy.
The client is receiving a massive blood transfusion (6 units in 3 hours) for hemorrhagic shock.
Understanding the therapy helps anticipate specific complications such as citrate toxicity, hyperkalemia, and circulatory overload.
2
Evaluate the telemetry and electrocardiogram options.
A prolonged QT interval indicates hypocalcemia (from citrate binding calcium). Tall, peaked T waves indicate hyperkalemia (from lysed banked red blood cells).
Both are life-threatening electrolyte imbalances directly caused by massive transfusions.
3
Evaluate the physical assessment options.
Crackles and jugular venous distention indicate transfusion-associated circulatory overload (TACO).
Rapid infusion of large volumes of blood products can easily overwhelm the cardiovascular system, leading to pulmonary edema.
4
Differentiate expected recovery signs from true complications.
A temperature of 99.1°F, a MAP of 72 mm Hg, and a urine output of 40 mL/hour are all normal or expected positive responses to shock resuscitation.
Intervening on expected positive responses would be inappropriate and potentially harmful.

Key Concept

Complications of Massive Blood Transfusion
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Topics

Reduction of Risk Potential

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