A nurse is assisting with monitoring a client who is receiving a unit of packed RBCs. Which of the following findings indicates the client is experiencing a hemolytic transfusion reaction?
Temperature 38.8° C (101.8° F)
Straw-colored urine
Apical pulse rate 58/min
Blood pressure 158/92 mm Hg
The Correct Answer is A
The correct answer is: a. Temperature 38.8° C (101.8° F)
Title: Choice A reason: A temperature of 38.8° C (101.8° F) is indicative of a fever, which is a common symptom of a hemolytic transfusion reaction. During such a reaction, the immune system attacks the transfused red blood cells, leading to their destruction and the release of substances that can cause a rise in body temperature.
Title: Choice B reason: Straw-colored urine is not typically associated with a hemolytic transfusion reaction. Hemolytic reactions often result in darker urine due to the presence of free hemoglobin released from destroyed red blood cells.
Title: Choice C reason: An apical pulse rate of 58/min is considered bradycardia if it is lower than the normal resting heart rate for adults, which ranges from 60 to 100 beats per minute. Bradycardia is not a direct indicator of a hemolytic transfusion reaction.
Title: Choice D reason: Elevated blood pressure, such as 158/92 mm Hg, can be a sign of various conditions but is not a specific indicator of a hemolytic transfusion reaction. The symptoms of such a reaction are more directly related to the destruction of red blood cells and the body’s response to it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as diarrhea, gastroenteritis, or early bowel obstruction.
Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.
Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.
Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.
Correct Answer is D
Explanation
After a tonic-clonic seizure, the nurse should first check the child for any injuries, particularly in the oral cavity. This is because during a seizure, the child's tongue may have been biten, or there may be other oral injuries. Therefore, it is essential to check the oral cavity for any injury or bleeding.
Offering sips of clear fluids is not a priority at this time as the child may still be disoriented and at risk of choking. Placing the child in a supine position is also not recommended because the child may have difficulty breathing due to muscle weakness or constriction of the airways. Administering an oral antiepileptic medication is not appropriate at this time unless prescribed by a healthcare provider.
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