A 65-year-old patient has just received a blood transfusion. Shortly after the transfusion begins, the patient complains of chills, back pain, and difficulty breathing. What is the most likely cause of these symptoms?

Febrile non-hemolytic transfusion reaction.

Allergic reaction.

Fluid overload.

Acute hemolytic transfusion reaction.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Febrile non-hemolytic transfusion reactions (FNHTRs) are common and typically present with fever, chills, and sometimes rigors. However, they do not usually cause severe symptoms such as back pain and difficulty breathing. FNHTRs are generally less severe and are caused by the recipient’s immune response to donor white blood cells or cytokines in the transfused blood.

Choice B Reason:

Allergic reactions to blood transfusions can range from mild to severe. Mild reactions may include itching, hives, and rash, while severe reactions (anaphylaxis) can cause difficulty breathing and hypotension. However, allergic reactions do not typically cause back pain, which is more indicative of a hemolytic process.

Choice C Reason:

Fluid overload, also known as transfusion-associated circulatory overload (TACO), can occur when too much blood is transfused too quickly. Symptoms include dyspnea, hypertension, and pulmonary edema. While difficulty breathing is a symptom of fluid overload, chills and back pain are not typical features.

Choice D Reason:

Acute hemolytic transfusion reaction (AHTR) is the most likely cause of the patient’s symptoms. AHTR occurs when the recipient’s immune system attacks the transfused red blood cells, leading to their destruction. This reaction can cause severe symptoms such as chills, fever, back pain, and difficulty breathing. It is a medical emergency that requires immediate intervention to prevent serious complications, including kidney failure and shock.

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Correct Answer is B

Explanation

Choice A Reason:

Increased appetite is not typically associated with anemia. Anemia generally leads to symptoms related to decreased oxygen-carrying capacity of the blood, such as fatigue, weakness, and shortness of breath. Increased appetite is more commonly linked to other conditions, such as hyperthyroidism or certain metabolic disorders.

Choice B Reason:

Fatigue is a common and significant symptom of anemia. When hemoglobin levels are low, the body’s tissues do not receive adequate oxygen, leading to feelings of tiredness and exhaustion. This is because hemoglobin is responsible for transporting oxygen from the lungs to the rest of the body. In anemia, the reduced oxygen delivery results in decreased energy levels and persistent fatigue.

Choice C Reason:

Weight gain is not typically associated with anemia. In fact, some forms of anemia, such as those caused by chronic diseases or malnutrition, may lead to weight loss rather than gain. Weight gain can be associated with other health issues, such as hypothyroidism or fluid retention, but not directly with anemia.

Choice D Reason:

Hypertension is not a common manifestation of anemia. Anemia usually leads to symptoms like pallor, shortness of breath, and fatigue due to the reduced oxygen-carrying capacity of the blood. Hypertension, or high blood pressure, is more commonly associated with cardiovascular diseases, kidney disorders, or endocrine conditions.

A. This test will measure the intraocular pressure of the eye. B. Tonometry will allow inspection of the optic disc for signs of degeneration. C. Tonometry is performed to evaluate peripheral vision. D. This test will diagnose the type of your glaucoma.

Correct Answer is A

Explanation

Choice A Reason:

Tonometry is a diagnostic test that measures the intraocular pressure (IOP) inside the eye. This measurement is crucial for detecting and managing glaucoma, as elevated IOP is a significant risk factor for the disease. By measuring the pressure, healthcare providers can assess the risk of optic nerve damage and initiate appropriate treatments to prevent vision loss.

Choice B Reason:

Tonometry does not allow for the inspection of the optic disc for signs of degeneration. This function is typically performed using ophthalmoscopy or optical coherence tomography (OCT), which provide detailed images of the optic nerve and retina. These tests are essential for evaluating the structural damage caused by glaucoma but are not part of the tonometry procedure.

Choice C Reason:

Tonometry is not performed to evaluate peripheral vision. Peripheral vision is assessed using perimetry or visual field testing, which maps the field of vision and detects areas of vision loss. This test helps determine the extent of visual impairment caused by glaucoma but is separate from tonometry.

Choice D Reason:

Tonometry does not diagnose the type of glaucoma. While it measures intraocular pressure, diagnosing the specific type of glaucoma requires a comprehensive eye examination, including gonioscopy to examine the drainage angle of the eye and other tests to assess optic nerve health and visual field. Therefore, tonometry is just one component of the diagnostic process.

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A 65-year-old patient has just received a blood transfusion. Shortly after the transfusion begins, the patient complains of chills, back pain, and difficulty breathing. What is the most likely cause of these symptoms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A nurse is reinforcing teaching about a tonometry examination with a client who has manifestations of glaucoma. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

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