A client who received a blood transfusion 4 weeks ago now exhibits symptoms including fever, rash, diarrhea, and pancytopenia.
What complication might be responsible for these symptoms?
Delayed hemolytic reaction.
Graft-versus-host disease.
Transfusion-associated graft-versus-host disease (TA-GVHD)
Post-transfusion purpura.
The Correct Answer is C
Choice A rationale:
Delayed hemolytic reaction occurs more than 24 hours after a blood transfusion and is characterized by a drop in hemoglobin levels, jaundice, and a positive direct antiglobulin test (Coombs test)
It does not typically present with fever, rash, and pancytopenia, so it is not the best choice for the given symptoms.
Choice B rationale:
Graft-versus-host disease (GVHD) is a condition where donor T lymphocytes attack the recipient's tissues, often seen in bone marrow or stem cell transplant recipients.
While it can cause pancytopenia, it typically occurs within a few weeks of transplantation, not four weeks after a blood transfusion.
Therefore, it is less likely to be the cause in this scenario.
Choice C rationale:
Transfusion-associated graft-versus-host disease (TA-GVHD) occurs when viable T lymphocytes in the transfused blood attack the recipient's tissues.
Symptoms can include fever, rash, diarrhea, and pancytopenia.
TA-GVHD is a delayed complication of transfusion that typically presents about 1 to 6 weeks post-transfusion, making it the most likely cause of the symptoms described in the scenario.
Choice D rationale:
Post-transfusion purpura is a rare condition that occurs 5 to 12 days after a transfusion and is characterized by sudden severe thrombocytopenia (low platelet count) and bleeding, often in the form of purpura.
It does not typically present with fever, rash, and pancytopenia, so it is not the best choice for the given symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Choice A rationale:
Fever is a potential sign of a delayed transfusion reaction.
Delayed transfusion reactions can occur several days after a blood transfusion and may present with fever as a symptom.
This can be indicative of hemolysis or an immune response to the transfused blood.
Choice C rationale:
Jaundice is another sign that the nurse should monitor for delayed transfusion reactions.
Jaundice can be a result of hemolysis, where the red blood cells are destroyed, leading to an increase in bilirubin levels in the bloodstream.
Choice B rationale:
Increased urine output is not typically associated with delayed transfusion reactions.
Delayed reactions are more likely to manifest as fever, jaundice, or other signs of hemolysis.
Choice D rationale:
Hypertension is not a common sign of delayed transfusion reactions.
These reactions are more likely to present with symptoms related to the destruction of red blood cells, such as fever and jaundice.
Choice E rationale:
Decreased oxygen saturation is not a typical sign of delayed transfusion reactions.
It is important to monitor oxygen saturation during a blood transfusion, but this is more relevant to immediate transfusion reactions, such as transfusion-related acute lung injury (TRALI)
Correct Answer is B
Explanation
Choice A rationale:
"I'm feeling weak and dizzy." Rationale: Weakness and dizziness can be symptoms of anemia, which is often associated with low hemoglobin levels.
However, these symptoms alone are not a definitive indication for blood transfusion.
Other factors, such as the patient's overall clinical condition and the cause of the low hemoglobin, need to be considered.
Choice B rationale:
"My hemoglobin is 7 g/dL, so I need a transfusion." Rationale: This statement indicates that the patient is aware of their low hemoglobin level and believes they need a transfusion.
The hemoglobin level of 7 g/dL is a common threshold used as an indication for blood transfusion, especially in symptomatic patients.
This choice is correct because it aligns with the appropriate clinical indication for a transfusion based on the hemoglobin level.
Choice C rationale:
"I had orthopedic surgery yesterday." Rationale: While surgery can lead to blood loss, the statement alone does not provide sufficient information to determine if a transfusion is necessary.
The decision to transfuse blood should be based on the patient's hemoglobin level, overall clinical condition, and the extent of blood loss during surgery.
Choice D rationale:
"I have a stable cardiovascular disease." Rationale: The presence of stable cardiovascular disease is not directly related to the need for a blood transfusion based on a hemoglobin level of 7 g/dL.
The decision to transfuse should primarily be based on the patient's hemoglobin level and symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.