A nurse is caring for a patient who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the patient is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?
Allergic
Hemolytic
Acute pain
Febrile
The Correct Answer is B
A. Allergic – An allergic reaction typically presents with itching, rash, and wheezing rather than fever, chills, and hematuria.
B. Hemolytic – Correct Answer. A hemolytic reaction occurs when the immune system attacks transfused red blood cells due to incompatibility. Symptoms include fever, chills, hypotension, back pain, and hematuria (red-tinged urine). This is a medical emergency requiring immediate intervention.
C. Acute pain – Acute pain transfusion reaction is rare and mainly presents with severe chest, back, and joint pain, without fever or hematuria.
D. Febrile – Febrile reactions cause fever and chills but do not typically cause hematuria, which is indicative of hemolysis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Regular insulin is the only insulin type that can be administered intravenously and is used in DKA treatment.
B. Lantus (glargine) is a long-acting insulin and is not used in acute situations.
C. Mixed insulins (intermediate and short-acting) are not appropriate for IV administration.
D. NPH is an intermediate-acting insulin and is not suitable for IV use.
Correct Answer is A
Explanation
A. Administer antibiotics when available. – Correct Answer. Bacterial meningitis is a medical emergency. The priority is to start IV antibiotics as soon as possible to prevent complications such as sepsis, increased ICP, and neurological damage.
B. Reduce environmental stimuli. – Incorrect. While reducing stimuli helps with photophobia and headache, it is not the priority over immediate antibiotic therapy.
C. Document intake and output. – Incorrect. Monitoring fluid balance is important, but it does not directly treat the infection.
D. Maintain seizure precautions. – Incorrect. Seizure precautions are necessary, but rapid antibiotic administration takes precedence.
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