A nurse is assessing a patient who is receiving a blood transfusion.
The nurse observes that the patient has developed fever, chills, back pain, chest pain, dyspnea, and jaundice.
What type of transfusion reaction is the patient most likely experiencing?
Febrile nonhemolytic reaction.
Allergic reaction.
Acute hemolytic reaction.
Transfusion-associated circulatory overload.
The Correct Answer is C
Acute hemolytic reaction.
Choice A rationale:
A febrile nonhemolytic reaction typically presents with fever, chills, and rigors but is not associated with back pain, chest pain, dyspnea, or jaundice.
It is often caused by antibodies to leukocytes or platelets in the donor's blood.
This reaction is usually mild and self-limiting.
Choice B rationale:
Allergic reactions typically present with symptoms like urticaria, pruritus, flushing, and can include mild to moderate fever, but they do not cause back pain, chest pain, dyspnea, or jaundice.
These reactions are usually associated with sensitivity to plasma proteins or allergens in the blood product.
Choice C rationale:
Acute hemolytic reactions involve the rapid destruction of red blood cells, leading to the release of hemoglobin into the bloodstream.
This can cause fever, chills, back pain, chest pain, dyspnea, and jaundice, making it the most likely reaction in this case.
It is usually due to ABO incompatibility between the donor and recipient blood.
Choice D rationale:
Transfusion-associated circulatory overload (TACO) typically presents with symptoms related to volume overload, such as pulmonary edema, hypertension, and tachycardia.
It does not typically manifest with fever, chills, back pain, chest pain, dyspnea, or jaundice.
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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