Nurse Daniel is caring for a client receiving a transfusion of packed red blood cells (PRBCs). The client started to vomit and to be nauseous. Client’s blood pressure is 95/40 mm Hg from a baseline of 110/70 mm Hg. The client’s temperature is 100.5°F orally from a baseline of 99.5°F orally. The nurse understands that client may be experiencing which of following?

Correct Answer: D. Septicemia

Septicemia happens with the transfusion of blood that is contaminated with microorganisms. Assessment includes the rapid onset of high fever and chills, hypotension, nausea, diarrhea, vomiting, and shock. Fever and/or chills are most commonly associated with a febrile, non-hemolytic reaction, however; they can also be the first sign of a more serious acute hemolytic reaction, TRALI, or septic transfusion reaction. If the temperature rises 1 C or higher from the temperature at the start of the transfusion, the transfusion should be stopped.

• Option A: Circulatory overload causes hypertension, cough, dyspnea, chest pain, tachycardia, and wheezing upon auscultation. Dyspnea, or shortness of breath, is a concerning sign that can often be seen with more severe reactions including anaphylaxis, TRALI, and TACO. It can also be seen by itself without accompanying symptoms.
• Option B: Delayed reaction can occur days to years after a transfusion. It causes fever, rashes, mild jaundice, and oliguria or anuria. Typically caused by an anamnestic response to a foreign antigen that the patient was previously exposed to (generally by prior transfusion or pregnancy).
• Option C: Hypocalcemia causes paresthesias, tetany, muscle cramps, hyperactive reflexes, positive Trousseau’s sign, and positive Chovstek’s sign. Hypocalcemia is said to be present when the total serum calcium concentration is less than 8.8 mg/dl. The disorder may be acquired or inherited but its presentation can vary- from asymptomatic to life-threatening. Hypocalcemia is commonly seen in hospitalized patients and for the most part, is mild in nature and only requires supportive treatment.