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1. A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a transfusion reaction?

- Temperature of 38.8 degrees C (101.8 F)
- Straw-colored urine
- Apical pulse rate of 58
- Blood pressure of 158/92 mm Hg

Answer :

Final answer:

A high temperature, straw-colored urine, a low apical pulse rate, and high blood pressure are indications that a patient is experiencing a transfusion reaction during a blood transfusion.

Explanation:

A transfusion reaction can occur when a patient receives a blood transfusion with an incompatible blood type. In this case, if a patient is receiving packed RBCs and experiences a transfusion reaction, some possible findings would include a high temperature (38.8 degrees Celsius or 101.8 degrees Fahrenheit), straw-colored urine, a low apical pulse rate (58 beats per minute), and high blood pressure (158/92 mmHg).

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