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:
Lactated Ringer's solution is a volume expander, not a therapy for improving oxygen-carrying capacity.
It can increase blood volume but does not address the underlying cause of anemia or hypoxia.
Choice B rationale:
Hemostatic agents like protamine sulfate are used to reverse the anticoagulant effects of heparin.
They are not indicated for improving oxygen-carrying capacity in anemic patients.
Choice C rationale:
Oxygen therapy delivered through a nasal cannula or mask is indeed a therapy to enhance oxygen-carrying capacity.
It provides supplemental oxygen to improve oxygen saturation in the blood, which can alleviate hypoxia in anemic patients.
Choice D rationale:
Erythropoietin injections can stimulate the production of red blood cells in the bone marrow.
This therapy can increase the patient's hemoglobin levels and improve oxygen-carrying capacity, making it a suitable recommendation for a patient with hypoxia due to anemia.
For , choices A, C, and D are correct as they are examples of volume expanders that can increase blood volume and circulation without adding blood cells.
For , choice C is correct as hemostatic agents like vitamin K or tranexamic acid can promote clotting and stop bleeding in a patient with a bleeding disorder.
For , choice D is correct as erythropoietin injections can stimulate the production of red blood cells and help alleviate hypoxia in a patient with anemia.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale:
A+ blood can be safely transfused to a client with blood type O-.
The rationale is that the recipient, in this case, does not have antibodies against the A antigen, which is present on A+ blood.
Therefore, there is no antigen-antibody reaction.
Choice B rationale:
B- blood can be safely transfused to a client with blood type O-.
The rationale is similar to choice A, as the recipient does not have antibodies against the B antigen, which is present on B- blood.
Choice C rationale:
AB+ blood contains both A and B antigens and RhD antigen, which can potentially react with antibodies present in a client with blood type O-.
Therefore, it is not safe to transfuse AB+ blood to a client with blood type O-.
Choice D rationale:
O+ blood can be safely transfused to a client with blood type O-.
The rationale is that O+ blood does not have A or B antigens, which could react with antibodies present in the recipient.
Choice E rationale:
O- blood is compatible with blood type O- because it does not contain A, B, or RhD antigens, which could be targeted by antibodies in the recipient.
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