A client postoperative fractured hip repair is prescribed 1 unit of packed cells. The nurse monitoring the transfusion notes a 2 degree temperature elevation. Which action is appropriate? A. Stop the transfusion B. Notify the charge nurse of the temperature C. Recheck the temperature with another thermometer D. Apply extra blankets

Postoperative care is a crucial period when the patient recovers from the surgery. It involves rigorous monitoring to spot early signs of complications, such as infections, bleeding, or reactions to treatments. For a patient who has undergone a hip repair surgery, close observation is especially important.

During this time, it is the nurse's responsibility to manage pain, monitor vital signs, ensure the patient is adequately hydrated and nourished, and maintain a safe environment to prevent falls or additional injuries. Interventions might also include administering prescribed medications, including blood transfusions if necessary.

Monitoring for Complications

In the case of our exercise, the nurse notes a 2-degree temperature elevation, which requires a swift assessment and response. An increase in temperature could potentially indicate an infection or a transfusion reaction. Therefore, continuous temperature monitoring is recommended to detect and address issues promptly, minimizing the risk of them escalating.

Blood transfusions can be life-saving, but they can also lead to transfusion reactions. These reactions range from mild to severe and can manifest as fever, chills, itching, or respiratory distress. It's imperative for nursing staff to be vigilant when a patient is receiving a transfusion.

Recognizing the Signs

Temperature elevation, as noted in the exercise, could be the first sign of a transfusion reaction. Other signs to look for include hives, anxiety, back pain, and dark urine, indicating a hemolytic reaction, which is particularly dangerous.

Upon detecting signs of a transfusion reaction, the protocol usually involves stopping the transfusion, assessing the patient's condition, administering antihistamines or steroids if ordered, and notifying a physician swiftly. The key is to act promptly to reduce potential harm to the patient.

Nursing interventions are actions taken by nurses to enhance patient outcomes. These may be independent, dependent, or collaborative actions based on the patient's condition and prescribed treatments.

Effective Decision-Making

In our scenario, the nurse must make a wise decision considering the potential for a serious transfusion reaction. After noting the temperature rise, the best initial nursing intervention is to alert the charge nurse (Option B). This promotes teamwork and rapid response, harnessing the collective expertise of the nursing staff.

Stopping the transfusion might be necessary if additional signs of a reaction develop, rechecking the temperature could ensure the accuracy of the initial reading, and applying extra blankets may be appropriate only if hypothermia were a concern, but these actions do not directly address or escalate the issue as effectively as notifying the appropriate authority.