A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
Allergic
Acute pain
Febrile
Hemolytic
The Correct Answer is D
A. Allergic: Allergic reactions typically involve symptoms such as hives, itching, and sometimes anaphylaxis, but not usually fever, chills, or hematuria (red-tinged urine).
B. Acute pain: Acute pain transfusion reaction is characterized by severe pain but not usually accompanied by fever, chills, or hematuria.
C. Febrile: Febrile reactions involve fever and chills but do not typically include red-tinged urine, which indicates hemolysis of red blood cells.
D. Hemolytic: A hemolytic transfusion reaction involves the destruction of red blood cells, leading to fever, chills, and red-tinged urine due to the presence of hemoglobin from lysed red cells in the urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. Steak - Red meats like steak are high in vitamin B12, making them an excellent choice for individuals with B12 deficiency.
B. Low fat milk - Dairy products, including milk, are good sources of vitamin B12 and should be included in the diet.
C. Grilled salmon - Fish such as salmon is rich in vitamin B12, making it a beneficial food for addressing B12 deficiency.
D. Green leafy vegetables - While nutritious, green leafy vegetables are not significant sources of vitamin B12. B12 is primarily found in animal products.
E. Scrambled eggs - Eggs contain a good amount of vitamin B12, making them a suitable option for dietary management of deficiency.
Correct Answer is A
Explanation
A. Stop the infusion of blood. The client’s symptoms suggest a possible acute hemolytic transfusion reaction, which is a life-threatening emergency. The first and most critical action is to stop the blood transfusion immediately to prevent further reaction and additional hemolysis.
B. Inform the provider: This is an important action but should be done after stopping the transfusion to prevent further complications.
C. Obtain a urine specimen: This is done to check for hemoglobinuria, but it is not the immediate priority.
D. Notify the laboratory: This is part of the follow-up procedure but should be done after stopping the transfusion and stabilizing the patient.
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