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 C
Explanation
A. Elevate the limb and apply ice. Elevating the limb and applying ice can help reduce blood flow to the area and minimize swelling. However, it is not the immediate priority in managing active, profuse bleeding.
B. Apply a tourniquet just below the elbow. A tourniquet should be a last resort due to the risk of cutting off blood flow and potential limb damage. It's typically used in life-threatening situations where other methods fail to control bleeding.
C. Apply direct pressure over the wound. The immediate priority for controlling profuse bleeding is to apply direct pressure to the wound to stop or reduce the bleeding. This is a standard first-line intervention in hemorrhage management.
D. Clean the wound. Cleaning the wound is important to prevent infection, but it is not the first priority when dealing with active, profuse bleeding.
Correct Answer is A
Explanation
A. Heart rate: Adequate fluid resuscitation in burn patients helps to restore intravascular volume, improving circulation and perfusion. A decrease in heart rate indicates improved cardiac output and reduced compensatory tachycardia, suggesting adequate fluid replacement.
B. Weight: Fluid replacement can lead to an increase in weight due to the volume of fluids administered, not a decrease.
C. Urine output: Adequate fluid resuscitation typically increases urine output as renal perfusion improves.
D. Blood Pressure (BP): While BP can stabilize with adequate fluid resuscitation, it is not as direct an indicator as a decrease in heart rate in reflecting improved perfusion and hydration status.
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