A nurse is caring for a client who is receiving a unit of packed RBCs. About 15 min following the start of the transfusion, the nurse notes that the client is flushed and febrile, and reports chills. To help confirm that the client is having an acute hemolytic transfusion reaction, the nurse should observe for which of the following manifestations?

Jaw Pain

Urticaria

Distended neck veins

Hypotension

Answer and Explanation

The Correct Answer is D

A. Jaw Pain: Jaw pain is not typically associated with a hemolytic transfusion reaction. It may be more relevant in cardiac issues or in rare cases of referred pain, but it is not an indicator of transfusion reaction.

B. Urticaria: Urticaria (hives) is associated with allergic reactions, not specifically with hemolytic reactions. Acute hemolytic reactions are characterized more by systemic symptoms like hypotension and fever.

C. Distended neck veins: Distended neck veins suggest fluid overload or cardiac issues but are not characteristic of an acute hemolytic reaction.

D. Hypotension: Hypotension is a common sign of an acute hemolytic transfusion reaction. This occurs when the immune system attacks transfused red blood cells, leading to hemolysis, which can cause shock and a drop-in blood pressure.

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Correct Answer is B

Explanation

A. Skin color: While skin color can show signs of reactions, it is a secondary measure. Temperature changes can be more immediately significant in assessing transfusion reactions.

B. Temperature: Temperature is the priority because a fever can indicate an infection or may develop as a sign of a transfusion reaction. Monitoring baseline temperature helps quickly identify febrile reactions to the transfusion.

C. Hemoglobin level: Although important to verify, the hemoglobin level is part of the overall assessment but does not directly predict or prevent transfusion reactions.

D. Fluid intake: Fluid intake is monitored for fluid overload risk but is not as immediate in the prevention of transfusion reactions.

A. Cryoprecipitates B. Frozen Packed Red Blood Cells (PRBCs) C. Fresh frozen plasma (FFP) D. Platelets

Correct Answer is C

Explanation

A. Cryoprecipitates: Cryoprecipitates contain fibrinogen, factor VIII, von Willebrand factor, and factor XIII, and are typically used for patients with specific factor deficiencies, such as hemophilia or fibrinogen deficiency, rather than general clotting disorders.

B. Frozen Packed Red Blood Cells (PRBCs): PRBCs are primarily used to treat anemia and to increase oxygen-carrying capacity, not to correct clotting factor deficiencies.

C. Fresh frozen plasma (FFP): Fresh frozen plasma (FFP) contains clotting factors and is administered to patients with clotting disorders to help manage bleeding by replenishing these factors.

D. Platelets: Platelets are administered to patients with thrombocytopenia or platelet dysfunction, not to replace clotting factors as needed in general clotting disorders.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse's priority before the transfusion begins?

Correct Answer is B

Explanation

The nurse is caring for a patient with a clotting disorder. Which should the nurse plan to administer?

Correct Answer is C

Explanation

The nurse is caring for a patient with stage IV Hodgkin disease. Where should the nurse expect to find enlarged lymph nodes during the assessment?

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