A nurse is collecting data on a patient who is receiving a unit of PRBCs.
Which of the following symptoms is a sign of an allergic transfusion reaction?
Wheezing
Flank pain
Elevated blood pressure
Distended neck veins
Answer and explanation The
The Correct Answer is A
Choice A rationale:
Wheezing is a common symptom of an allergic transfusion reaction. An allergic transfusion reaction occurs when the recipient’s immune system reacts to foreign proteins or allergens in the donor’s blood. Symptoms of an allergic reaction can range from mild to severe, and they typically include skin reactions such as hives and itching, as well as respiratory symptoms like wheezing. In severe cases, the reaction can cause difficulty breathing.
Choice B rationale:
Flank pain is not typically associated with an allergic transfusion reaction. It is more commonly a symptom of conditions affecting the kidneys or urinary tract. While flank pain can occur in a hemolytic transfusion reaction due to the rapid destruction of red blood cells, it is not a symptom of an allergic reaction.
Choice C rationale:
Elevated blood pressure is not a typical symptom of an allergic transfusion reaction. Allergic reactions more commonly cause symptoms such as hives, itching, and respiratory symptoms like wheezing. In severe cases, an allergic reaction can actually lead to a drop in blood pressure.
Choice D rationale:
Distended neck veins are not a typical symptom of an allergic transfusion reaction. They are more commonly associated with conditions that cause increased pressure in the right side of the heart. While distended neck veins can occur in a transfusion reaction due to fluid overload, they are not a symptom of an allergic reaction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Administering insulin is a crucial step in managing diabetic ketoacidosis (DKA), as insulin deficiency is a primary cause of DKA12. However, it is not the first action to take when a patient presents with both DKA and hypoxia. While insulin helps to reduce blood glucose levels and suppress the production of ketones, it does not address the immediate life-threatening condition of hypoxia.
Choice B rationale:
Hypoxia, or low levels of oxygen in the body, is a medical emergency that requires immediate attention. Supplemental oxygen can help increase the oxygen levels in the patient’s blood, thereby alleviating hypoxia. In the context of a patient with DKA and hypoxia, providing supplemental oxygen would be the first action to take to stabilize the patient’s condition before addressing the DKA12.
Choice C rationale:
Checking the patient’s glucose level is an important part of managing DKA, as hyperglycemia is a key feature of this condition. However, it is not the first action to take in this scenario. While monitoring glucose levels can guide the administration of insulin and other treatments for DKA, it does not address the immediate threat posed by hypoxia.
Choice D rationale:
Administering intravenous fluids is another important step in managing DKA12. Dehydration is a common complication of DKA due to excessive urination caused by high blood sugar levels. However, similar to Choices A and C, while it is an important part of treatment, it is not the first action to take when a patient presents with both DKA and hypoxia.
Correct Answer is B
Explanation
Choice A rationale:
Administering insulin to a client who is hyperventilating due to respiratory alkalosis would not be the appropriate action. Insulin is used to lower blood glucose levels in clients with hyperglycemia, such as those with diabetes mellitus. It does not directly address the issues of hyperventilation or respiratory alkalosis.
Choice B rationale:
Having the client breathe into a paper bag is the correct action in this case. When a person hyperventilates, they exhale more carbon dioxide (CO2) than they produce. This can lead to a state of respiratory alkalosis, where the blood becomes too alkaline due to the low levels of CO2. By breathing into a paper bag, the client re-inhales some of the exhaled CO2, helping to restore the balance of gases in the blood and alleviate the symptoms of respiratory alkalosis.
Choice C rationale:
Administering sodium bicarbonate to a client who is hyperventilating and has respiratory alkalosis would not be the appropriate action. Sodium bicarbonate is an alkalinizing agent used to treat conditions where there is too much acid in the body, such as metabolic acidosis. In this case, the client’s body is too alkaline due to the respiratory alkalosis, so administering an alkalinizing agent would exacerbate the condition.
Choice D rationale:
Having the client place their head between their knees would not be the appropriate action for a client who is hyperventilating due to respiratory alkalosis. This position is often used to help alleviate symptoms of dizziness or fainting, but it does not address the underlying issue of the imbalance of gases in the blood due to hyperventilation.
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