A nurse is assessing a patient who has just received a blood transfusion.
Select all the signs or symptoms the nurse should monitor for delayed transfusion reactions.
Fever.
Increased urine output.
Jaundice.
Hypertension.
Decreased oxygen saturation.
Correct Answer : A,C
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)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
This choice is incorrect.
While individuals with AB+ blood type are considered universal recipients for plasma components, they cannot receive blood from donors with the O- blood type.
Choice B rationale:
This choice is also incorrect.
AB+ individuals can receive blood from AB+ and AB- donors, but not exclusively from them.
Choice C rationale:
This choice is incorrect as well.
AB+ individuals can receive blood from AB+ donors, A+ donors, and B+ donors, but this statement does not provide a complete and accurate picture of their compatibility.
Choice D rationale:
This choice is correct.
Individuals with blood type AB+ can safely receive blood from donors with blood types AB+, A+, A-, or B+.
The rationale behind this is that AB+ individuals have both A and B antigens on their red blood cells and do not have anti-A or anti-B antibodies in their plasma.
Therefore, they can receive blood with ABO and RhD compatibility.
Correct Answer is B
Explanation
Choice A rationale:
AB+ blood type contains both A and B antigens as well as the Rh antigen (positive)
Blood type O+ has neither A nor B antigens but does have the Rh antigen.
Therefore, AB+ blood cannot be safely transfused to a client with blood type O+ as it would lead to a mismatch in ABO compatibility.
Choice B rationale:
O- blood type is the universal donor for red blood cell transfusions.
It lacks both A and B antigens as well as the Rh antigen, making it compatible with all other blood types.
Since the client in question has blood type O+, which is Rh-positive, O- blood can be safely transfused without any ABO or Rh incompatibility.
Choice C rationale:
A+ blood type contains A antigens and the Rh antigen (positive)
Blood type O+ lacks A antigens but does have the Rh antigen.
Therefore, A+ blood is not compatible with O+ blood due to ABO incompatibility.
Choice D rationale:
B+ blood type contains B antigens and the Rh antigen (positive)
Blood type O+ lacks B antigens but does have the Rh antigen.
Therefore, B+ blood is not compatible with O+ blood due to ABO incompatibility.
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