A nurse is assessing a client who is receiving a unit of packed red blood cells. Which of the following findings is a manifestation of acute hemolytic reaction?
Distended neck veins
Client report of low back pain
A productive cough
Client report of tinnitus
The Correct Answer is B
Choice A reason: Distended neck veins is not a manifestation of acute hemolytic reaction, but it may indicate fluid overload, which is another possible complication of blood transfusion. Fluid overload may occur when the blood volume or rate of infusion exceeds the client's circulatory capacity. Fluid overload may manifest as dyspnea, crackles, edema, hypertension, or tachycardia.
Choice B reason: Client report of low back pain is a manifestation of acute hemolytic reaction, which is a life-threatening condition that occurs when the donor blood is incompatible with the recipient's blood. Acute hemolytic reaction may occur within minutes or hours of the transfusion and may cause the destruction of the transfused red blood cells. Acute hemolytic reaction may manifest as fever, chills, low back pain, hemoglobinuria, hypotension, or shock.
Choice C reason: A productive cough is not a manifestation of acute hemolytic reaction, but it may indicate a respiratory infection, which is a potential risk of blood transfusion. Blood transfusion may transmit infectious agents, such as bacteria, viruses, or parasites, from the donor to the recipient. A productive cough may also be a sign of pulmonary edema, which may result from fluid overload or transfusion-related acute lung injury (TRALI).
Choice D reason: Client report of tinnitus is not a manifestation of acute hemolytic reaction, but it may indicate ototoxicity, which is a possible adverse effect of some medications, such as aminoglycosides, loop diuretics, or salicylates. Ototoxicity may damage the inner ear or the auditory nerve and cause hearing loss, tinnitus, or vertigo. The nurse should assess the client's medication history and monitor the client's hearing function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Naloxone is not the correct medication. Naloxone is an opioid antagonist that reverses the effects of opioid overdose, such as respiratory depression, sedation, and hypotension. Naloxone has no effect on magnesium sulfate, which is a mineral and electrolyte that is used to prevent seizures in clients with preeclampsia or eclampsia.
Choice B reason: Protamine is not the correct medication. Protamine is a heparin antagonist that reverses the effects of heparin overdose, such as bleeding, bruising, and thrombocytopenia. Protamine has no effect on magnesium sulfate, which is not an anticoagulant.
Choice C reason: Calcium gluconate is the correct medication. Calcium gluconate is a calcium salt that antagonizes the effects of magnesium sulfate overdose, such as hypotension, bradycardia, respiratory depression, and muscle weakness. Calcium gluconate is the antidote for magnesium sulfate toxicity, which can occur when the serum magnesium level is above 7.5 mEq/L. The nurse should monitor the client's vital signs, deep tendon reflexes, and urine output, and report any signs of toxicity to the provider.
Choice D reason: Flumazenil is not the correct medication. Flumazenil is a benzodiazepine antagonist that reverses the effects of benzodiazepine overdose, such as drowsiness, confusion, and coma. Flumazenil has no effect on magnesium sulfate, which is not a sedative.
Correct Answer is D
Explanation
Choice A reason: "Place one tablet under your tongue every 5 minutes for 30 minutes to relieve chest pain." is not the correct statement. This is an incorrect and potentially dangerous instruction, as it can cause overdose and severe hypotension. The nurse should instruct the client to place one tablet under the tongue at the first sign of chest pain, and repeat every 5 minutes for up to three doses, if needed. The client should call 911 if the pain is not relieved after the first dose.
Choice B reason: "Nitroglycerin decreases chest pain by dissolving blood clots that are occluding the arteries." is not the correct statement. This is a false and misleading explanation of how nitroglycerin works. Nitroglycerin does not dissolve blood clots, nor does it affect the occlusion of the arteries. Nitroglycerin is a vasodilator that relaxes the smooth muscle of the blood vessels, especially the veins. This reduces the preload and the oxygen demand of the heart, and relieves the chest pain caused by ischemia.
Choice C reason: "You can store the bottle of tablets in your bathroom medicine cabinet." is not the correct statement. This is an inappropriate and unsafe storage recommendation, as it can affect the potency and effectiveness of the medication. The nurse should instruct the client to store the bottle of tablets in a cool, dry, and dark place, away from heat, moisture, and light. The client should also keep the bottle tightly closed and replace it every 6 months, or as directed by the provider.
Choice D reason: "Nitroglycerin dilates cardiac blood vessels to deliver more oxygen to the heart." is the correct statement. This is a simple and accurate description of how nitroglycerin helps to relieve anginal pain. Nitroglycerin dilates the coronary arteries, which supply blood and oxygen to the heart muscle. This improves the blood flow and oxygen delivery to the ischemic areas of the heart, and reduces the pain and discomfort.
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