A nurse is assessing a patient who received a blood transfusion 2 hours ago.
The nurse notes that the patient has developed dyspnea, orthopnea, tachypnea, and crackles on lung auscultation.
Which type of transfusion reaction should the nurse suspect?

Transfusion-related acute lung injury (TRALI)

Transfusion-associated circulatory overload (TACO)

Allergic reaction.

Febrile nonhemolytic reaction.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Transfusion-related acute lung injury (TRALI) is characterized by acute respiratory distress and is usually not associated with abdominal symptoms.

TRALI is more common in patients receiving plasma-containing blood products.

Choice B rationale:

Transfusion-associated circulatory overload (TACO) occurs when a patient receives a volume of blood or blood products that exceeds their circulatory system's capacity.

Symptoms include dyspnea, orthopnea, tachypnea, and crackles on lung auscultation, which match the symptoms described in the question.

This condition is more likely when blood products are transfused too rapidly or in excessive volume.

Choice C rationale:

Allergic reactions to blood transfusions typically present with symptoms like itching, hives, and flushing, rather than the respiratory symptoms and crackles on lung auscultation described in the question.

Choice D rationale:

Febrile nonhemolytic reactions are characterized by fever and chills and do not typically manifest as dyspnea, orthopnea, tachypnea, or crackles on lung auscultation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Transfusion-associated circulatory overload (TACO) is characterized by symptoms related to fluid overload, such as dyspnea and fluid accumulation, but not abdominal symptoms like abdominal pain, nausea, vomiting, and diarrhea.

Choice B rationale:

Transfusion-related acute lung injury (TRALI) primarily presents with respiratory symptoms and is not associated with gastrointestinal symptoms like nausea, vomiting, and diarrhea.

Choice C rationale:

Acute hemolytic reactions occur when there is a mismatch between the donor and recipient blood types, resulting in rapid destruction of transfused red blood cells.

Symptoms include abdominal pain, nausea, vomiting, and diarrhea, which are consistent with the client's presentation described in the question.

Choice D rationale:

Allergic reactions to blood transfusions typically present with symptoms like itching, hives, and flushing, but not with gastrointestinal symptoms like abdominal pain, nausea, vomiting, and diarrhea.

A. "I'll choose a site with infiltration or phlebitis.” B. "I'll use the same IV line for other medications.” C. "I'll avoid using sites with edema or infection.” D. "I'll use a 24-gauge IV catheter for the transfusion.”

Correct Answer is C

Explanation

Choice A rationale:

Choosing a site with infiltration or phlebitis is not appropriate for a blood transfusion.

Infiltration can lead to the transfused blood leaking into the surrounding tissues, and phlebitis can cause discomfort and complications.

A suitable site should be chosen for the transfusion.

Choice B rationale:

Using the same IV line for other medications without flushing it between medications can lead to drug interactions or contamination.

It is generally not recommended to mix blood transfusions with other medications in the same line.

Choice C rationale:

Avoiding sites with edema or infection is a crucial consideration when selecting an intravenous site for a blood transfusion.

Using a site with edema can make it difficult to insert the catheter, and using a site with infection can introduce pathogens into the bloodstream.

Choice D rationale:

Using a 24-gauge IV catheter for a blood transfusion may not be suitable for all patients.

The size of the catheter should be appropriate for the type of blood product being transfused and the patient's vein size.

A larger catheter may be necessary for blood products with higher viscosity.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a patient who received a blood transfusion 2 hours ago.The nurse notes that the patient has developed dyspnea, orthopnea, tachypnea, and crackles on lung auscultation.Which type of transfusion reaction should the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who received a blood transfusion starts experiencing abdominal pain, nausea, vomiting, and diarrhea. What type of transfusion reaction is the client likely experiencing?

Correct Answer is C

Explanation

A nurse is preparing to administer a blood transfusion to a patient. What should the nurse consider when selecting an intravenous site for the transfusion?

Correct Answer is C

Explanation

A patient is experiencing thrombocytopenia and needs a blood product to increase their platelet count.Which blood product should the nurse administer to address this condition?

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.

A nurse is educating a patient about blood transfusion alternatives.Which alternative to blood transfusion may be considered for patients with symptomatic anemia and ongoing bleeding?

A client who received a blood transfusion 4 weeks ago now exhibits symptoms including fever, rash, diarrhea, and pancytopenia.What complication might be responsible for these symptoms?

A client who received a blood transfusion develops symptoms such as epistaxis, hematuria, and menorrhagia 7 days after the transfusion.What complication could be responsible for these symptoms?

(Select all that apply): A nurse is educating a group of patients about alternatives to blood transfusion.Which of the following options are examples of volume expanders that can increase blood volume and circulation without adding blood cells? (Select three.)

A nurse is educating a group of healthcare professionals about blood transfusion safety measures.Which of the following actions should the nurse include as part of these safety measures? (Select all that apply)

(Select all that apply): A nurse is preparing to administer a blood transfusion.What are the nursing responsibilities before initiating the transfusion? Select three options.

A nurse is assessing a patient who received a blood transfusion 2 hours ago.
The nurse notes that the patient has developed dyspnea, orthopnea, tachypnea, and crackles on lung auscultation.
Which type of transfusion reaction should the nurse suspect?