A nurse is caring for a 15-year-old adolescent who is receiving a transfusion of packed RBCs.
Complete the diagram by dragging from the choices below to specify what condition the adolescent is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the adolescent's progress.

Answer and Explanation

The Correct Answer is []

The sudden onset of fever, chills, flank pain, chest tightness, hypotension, and tachycardia shortly after transfusion initiation strongly suggests an acute hemolytic transfusion reaction. This reaction occurs when the recipient’s immune system attacks transfused RBCs, leading to rapid intravascular hemolysis. Early recognition and immediate intervention are critical to prevent renal failure, shock, and death.

Rationale for correct choices:

• Acute hemolytic transfusion reaction: The client’s symptoms, including flank pain, fever, hypotension, tachycardia, and chest tightness occurring within minutes of transfusion, are classic signs of an acute hemolytic reaction. This occurs due to ABO incompatibility or immune-mediated destruction of transfused red blood cells. Hemolysis releases hemoglobin into circulation, which can lead to acute kidney injury and disseminated intravascular coagulation.

• Stop the transfusion and keep IV line open with normal saline: Stopping the transfusion immediately is the most critical intervention to prevent further hemolysis and systemic complications. Maintaining IV access with normal saline allows for administration of emergency medications and supports circulation. This helps preserve renal perfusion and reduces the risk of acute kidney injury from hemoglobin deposition.

• Notify the healthcare provider immediately: Prompt notification is essential because acute hemolytic reactions require urgent medical management, including laboratory testing, supportive care, and possible ICU transfer. The provider must be informed so that additional orders such as IV fluids, diuretics, or vasopressors can be initiated. Early escalation of care improves outcomes and reduces the risk of irreversible organ damage.

• Urine output and urine color: Monitoring urine output and color is essential because hemoglobin released from lysed RBCs can cause hemoglobinuria, leading to dark or cola-colored urine. Reduced urine output may indicate acute kidney injury from tubular obstruction and hemolysis. Early detection of renal compromise allows for timely interventions such as aggressive hydration. This parameter reflects the severity of intravascular hemolysis.

• Temperature changes: Fever is a hallmark of an acute hemolytic transfusion reaction due to immune activation and cytokine release during RBC destruction. Monitoring temperature trends helps evaluate progression or resolution of the reaction. A rising temperature may indicate worsening hemolysis or associated complications. Continuous monitoring is essential to assess response to interventions and detect deterioration early.

Rationale for incorrect choices:

• Circulatory overload transfusion reaction: Circulatory overload presents with hypertension, jugular venous distension, crackles, and pulmonary edema rather than flank pain or hemolysis-related symptoms. This client is hypotensive and febrile, which does not align with fluid overload. The rapid onset of fever and flank pain strongly indicates hemolytic rather than volume-related complications.

• Allergic transfusion reaction: An allergic reaction usually presents with urticaria, pruritus, and possibly mild wheezing, not hypotension, flank pain, or hemoglobinuria. It is typically mediated by hypersensitivity to plasma proteins rather than RBC destruction. The severity and systemic nature of this client’s symptoms indicate a hemolytic process. Allergic reactions are generally less severe and lack organ-related symptoms.

• Septic transfusion reaction: Although fever can occur in septic transfusion reactions, this presents with severe chills, hypotension, and shock but is associated with contaminated blood products and may include rigors and sepsis progression over time. Although some symptoms overlap, flank pain and signs of hemolysis are more specific to acute hemolytic reaction.

• Plan to administer epinephrine: Epinephrine is indicated for severe anaphylactic reactions involving airway compromise, bronchospasm, and cardiovascular collapse due to IgE-mediated hypersensitivity. This client’s presentation is more consistent with an acute hemolytic transfusion reaction rather than anaphylaxis. There are no signs of urticaria, wheezing, or airway obstruction that would justify epinephrine use.

• Insert an indwelling urinary catheter with urometer: Although urine output monitoring is important in suspected hemolysis, inserting a catheter is not an immediate first-line emergency intervention. The priority is to stop the transfusion, maintain IV access, and notify the provider before performing invasive procedures. Catheter insertion may be appropriate after stabilization if strict urine output measurement is needed.

• Administer antihistamine (diphenhydramine) IV: This is appropriate for mild allergic transfusion reactions characterized by itching, rash, or urticaria. In this case, the client has systemic signs such as hypotension, flank pain, fever, and chest tightness, which are indicative of hemolysis rather than a histamine-mediated allergic response. Antihistamines would not prevent or treat intravascular RBC destruction or its complications.

• Blood calcium levels: Calcium levels are not a priority indicator in acute transfusion reactions and are not directly affected in hemolytic reactions. The primary concerns are renal function and evidence of hemoglobin breakdown rather than electrolyte imbalance. Monitoring calcium would not provide useful information in assessing transfusion-related hemolysis.

• Presence of jugular vein distension: Jugular vein distension is associated with fluid overload or heart failure, not hemolytic transfusion reactions. The client is hypotensive and showing signs of shock rather than volume excess. This finding is inconsistent with the current clinical picture.

• Oxygen saturation: Although oxygen saturation can be monitored in any critically ill client, it is not the most specific indicator of hemolytic transfusion reaction progression. The key complications involve hemolysis and renal injury rather than primary respiratory failure. More direct indicators include urine changes and temperature trends.

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Correct Answer is C

Explanation

Acute glomerulonephritis is an inflammatory condition of the glomeruli, often following a streptococcal infection, which leads to impaired kidney filtration and fluid retention. Common manifestations include hematuria, edema, oliguria, and hypertension due to sodium and water retention. Nursing care focuses on monitoring fluid balance, controlling blood pressure, and preventing complications such as fluid overload and renal impairment. Close cardiovascular and renal monitoring is essential for safe management.

Rationale:
A. Collecting and straining all urine for sediment is not routinely required in acute glomerulonephritis. Urine is monitored for output, color, and presence of blood or protein, but straining is more commonly used for detecting calculi. In this condition, the primary concern is renal function and fluid balance rather than sediment collection.

B. Increasing fluid consumption is not appropriate because clients with acute glomerulonephritis often experience fluid retention and decreased urine output. Excess fluid intake can worsen edema and hypertension. Fluid restriction is typically considered based on the severity of oliguria and fluid overload.

C. Monitoring blood pressure every 4 hours is essential because hypertension is a common and potentially serious complication of acute glomerulonephritis. Increased fluid volume and sodium retention can elevate blood pressure, increasing the risk of cerebral or cardiovascular complications. Frequent monitoring allows early detection and management of worsening hypertension.

D. Implementing a protein-restricted diet is not routinely indicated in acute glomerulonephritis unless there is significant renal impairment. Protein restriction is more commonly associated with chronic kidney disease rather than acute, reversible inflammation. Dietary management in this condition primarily focuses on sodium restriction to control edema and blood pressure.

A. "My daughter can't drink orange juice." B. "I will switch her to whole milk now that she's old enough." C. "I should ensure that my daughter eats 1 ounce of meat every day." D. "I will steam carrots and cut them into small pieces for her."

Correct Answer is D

Explanation

Phenylketonuria (PKU) is an inborn error of metabolism caused by a deficiency of the enzyme phenylalanine hydroxylase, leading to accumulation of phenylalanine in the blood. High levels are toxic to the developing brain and can result in intellectual disability and neurologic damage if not managed. Dietary management is the cornerstone of treatment and involves strict restriction of high-protein foods while ensuring adequate nutrition for growth and development in infants and children.

Rationale:
A. Orange juice restriction is not required in PKU because fruits and juices are generally low in phenylalanine. The main concern is limiting high-protein foods such as meat, dairy, eggs, and certain grains rather than fruit-based products. Therefore, this statement does not reflect correct understanding.

B. Switching to whole milk is incorrect because milk contains high levels of phenylalanine and is strictly restricted in children with PKU. Infants and children with PKU require specialized medical formulas that provide nutrients without phenylalanine. Regular dairy products would worsen metabolic control and risk neurotoxicity.

C. Ensuring the child eats 1 ounce of meat daily is incorrect because meat is high in protein and phenylalanine and must be avoided in PKU management. Even small amounts can lead to harmful accumulation of phenylalanine. Protein intake is carefully controlled using special medical formulas rather than regular animal proteins.

D. Steaming carrots and cutting them into small pieces is appropriate because vegetables like carrots are low in phenylalanine and can be included in a controlled PKU diet. Proper preparation supports safe feeding for a 10-month-old while maintaining dietary restrictions. This demonstrates understanding of appropriate food selection in PKU management.

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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