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 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.
Correct Answer is D
Explanation
Allergic reaction.
Choice A rationale:
Transfusion-related acute lung injury (TRALI) usually presents with acute respiratory distress, not urticaria, pruritus, and flushing.
It is characterized by the sudden onset of dyspnea, hypoxemia, and pulmonary edema.
Choice B rationale:
Bacterial contamination of blood products can lead to sepsis, but the symptoms described in the question (urticaria, pruritus, and flushing) are not indicative of bacterial contamination.
Symptoms of bacterial contamination would typically include fever, chills, and signs of infection.
Choice C rationale:
Febrile nonhemolytic reactions can cause fever, chills, and rigors, but they are not associated with urticaria, pruritus, or flushing.
Choice D rationale:
An allergic reaction, also known as a hypersensitivity reaction, can manifest with symptoms like urticaria (hives), pruritus (itching), and flushing.
These symptoms are indicative of an allergic response to components in the blood product, such as plasma proteins or allergens.
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