Which initial assessment findings would the nurse expect in a client diagnosed with acute lymphocytic leukemia ALL? (SELECT ALL THAT APPLY)

A) Dyspnea, crackles, hypertension, and edema:
These symptoms suggest a transfusion-related acute lung injury (TRALI) or circulatory overload (TACO), both of which are potentially life-threatening conditions. In cases of TRALI or TACO, the nurse should stop the transfusion immediately but should NOT administer 0.9% normal saline because saline could exacerbate fluid overload and worsen pulmonary edema. Instead, the nurse should focus on managing respiratory distress, ensuring proper oxygenation, and notifying the healthcare provider for further intervention.

B) Low back pain, hypotension, and tachycardia:
These symptoms are typically indicative of a hemolytic transfusion reaction (HTR), which requires immediate intervention. In this case, the transfusion should be stopped immediately, but the nurse should begin administering 0.9% normal saline to help maintain the patient's blood pressure and promote kidney perfusion to prevent renal damage.

C) Urticaria, itching, wheezing, angioedema:
These symptoms are characteristic of a mild allergic reaction to the blood transfusion. In this case, the nurse should stop the transfusion and administer 0.9% normal saline to maintain the patient’s hydration and blood pressure while managing the allergic reaction. The healthcare provider may order antihistamines or corticosteroids to treat the allergic symptoms.

D) Chest tightness, fever, chills/rigors:
These are common symptoms of a febrile non-hemolytic transfusion reaction (FNHTR), which is generally not life-threatening. The nurse should stop the transfusion but can continue administering 0.9% normal saline to support hydration and circulation. FNHTR is often managed with antipyretics (e.g., acetaminophen) to reduce fever and chills, and the transfusion may be resumed if symptoms resolve

A) 3% Normal Saline:
Elevated ICP can lead to a life-threatening condition known as cerebral herniation, and it often triggers the Cushing’s triad—widened pulse pressure, bradycardia, and irregular respirations, all of which the nurse has noted. Hypertonic saline (such as 3% Normal Saline) is commonly used to manage increased ICP because it creates an osmotic gradient that draws fluid out of the brain tissue, reducing cerebral edema and lowering ICP. The goal is to reduce swelling and prevent further brain damage.

B) Nitroprusside:
Nitroprusside is a potent vasodilator that is used to treat hypertension and reduce afterload in conditions like heart failure or aortic dissection. However, in this case, nitroprusside is contraindicated because it could cause a drop in systemic blood pressure, which would worsen cerebral perfusion in a patient with elevated ICP.

C) Norepinephrine:
Norepinephrine is a vasopressor used to treat hypotension by increasing systemic vascular resistance and blood pressure. Although norepinephrine may be used to support blood pressure in critically ill patients, in this context of elevated ICP, the priority is to reduce ICP, not to increase blood pressure further. Increasing the systemic vascular resistance with norepinephrine could exacerbate ICP by increasing the volume of blood in the cranium

D) Furosemide:
Furosemide is a loop diuretic that can reduce fluid volume and help treat conditions like edema or heart failure. While furosemide can reduce overall fluid volume, it is not typically used to manage elevated ICP in this context. Diuretics like furosemide may have a role in managing cerebral edema, but they are not as effective as hypertonic saline in rapidly reducing ICP.