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 ["A","B","C","E"]
Explanation
Choice A rationale:
Ensuring that blood products meet quality and safety standards is a fundamental aspect of blood transfusion safety.
Blood products must be properly screened and tested for infectious diseases and compatibility to reduce the risk of adverse reactions in the recipient.
Choice B rationale:
Using the right blood product for the right patient at the right time is a critical safety measure.
Administering the wrong blood type or product can lead to severe and life-threatening reactions, such as hemolytic transfusion reactions.
Choice C rationale:
Applying a barcode system or electronic verification system for patient and product identification is essential for ensuring that the correct blood product is matched to the right patient.
This technology helps prevent administration errors.
Choice D rationale:
Administering blood products using reusable equipment is not recommended due to the risk of cross-contamination and infection transmission.
Single-use, disposable equipment is the standard for blood transfusion to enhance safety.
Choice E rationale:
Disposing of used blood products and materials according to hospital policy is crucial to prevent potential contamination and reduce the risk of infection transmission.
Proper disposal procedures are a part of overall transfusion safety protocols.
Choice D is not a recommended safety measure as using reusable equipment for blood transfusions can increase the risk of contamination and transmission of infections.
Therefore, it should not be included as part of blood transfusion safety measures.
Correct Answer is ["A","C"]
Explanation
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)
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