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. "My son will have to grow a beard." Growing a beard is irrelevant to managing hemophilia and preventing bleeding.

B. "My son will have to avoid contact sports." Avoiding contact sports is essential for children with hemophilia to reduce the risk of trauma and bleeding episodes due to their clotting factor deficiency.

C. "My son will have to avoid fresh foods such as fruit in his diet." Fresh foods like fruits do not pose a bleeding risk for hemophilia; dietary restrictions are generally unnecessary in managing this condition.

D. "My son will always have to live near a major hospital."While proximity to a healthcare facility can be helpful in emergencies, this is not a requirement for managing hemophilia, nor does it directly prevent bleeding episodes.

A. 2 hr B. 8 hr C. 6 hr D. 4 hr

Correct Answer is D

Explanation

A. 2 hr: While some patients may tolerate faster infusion rates, the maximum safe time is 4 hours, and there is no requirement to complete it in 2 hours.

B. 8 hr: Blood cannot be left out for 8 hours due to the increased risk of bacterial growth and contamination.

C. 6 hr: Infusing blood over 6 hours exceeds the safe time limit and poses a risk of bacterial contamination.

D. 4 hr: To reduce the risk of bacterial contamination, a unit of packed RBCs must be transfused within 4 hours of starting the infusion. This time frame ensures that the blood remains safe for the patient while minimizing exposure to room temperature.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching the parent of a child with hemophilia. Which of the following statements by the parent demonstrates understanding about preventing bleeding episodes?

Correct Answer is B

Explanation

A nurse is planning care for a client who is to receive one unit of packed RBCs. Within which of the following time spans must the nurse complete the infusion?

Correct Answer is D

Explanation

A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia?

The nurse is preparing to assist the physician with a bone marrow biopsy. Which of the following interventions is most important for the nurse to carry out before the procedure?

A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first?

The nurse is reviewing laboratory values for a female patient and notes a hemoglobin level of 8.2 g/100 mL (12-16) and a hematocrit level of 21% (37% -47%). These levels are found in patients with which condition?

The nurse is caring for a patient in sickle cell crisis. What is the rationale for providing warm compresses and blankets for this patient?

The nurse is caring for a patient who must undergo a splenectomy for treatment for idiopathic thrombocytopenic purpura (ITP). Which of the following statements best describes the rationale for the splenectomy?

The nurse is assessing a patient in a family practice clinic. The patient had extensive testing to rule out Hodgkin disease. Which of the following characteristics would indicate Hodgkin disease?