A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

Distended jugular veins.

Generalized urticaria.

Bilateral flank pain.

Blood pressure 184/92 mm Hg.

Answer and Explanation

The Correct Answer is B

A. Distended jugular veins may indicate fluid overload or congestive heart failure, not an allergic reaction.

B. Generalized urticaria, or hives, is a classic sign of an allergic transfusion reaction, presenting as an itchy rash or welts on the skin.

C. Bilateral flank pain is more indicative of a hemolytic reaction, particularly due to kidney involvement, rather than an allergic reaction.

D. A blood pressure of 184/92 mm Hg may suggest hypertension or a reaction, but it is not specific to allergic transfusion reactions, which are characterized by skin symptoms like urticaria.

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Correct Answer is ["B","C","D","E","F"]

Explanation

A. Hanging a bag of 0.9% normal saline with 5% dextrose (D5%NS) is incorrect; only normal saline (0.9% NS) should be used to prime the blood transfusion line to avoid hemolysis.

B. Verifying the client's name and blood type with a second nurse is a critical safety measure to prevent transfusion reactions and ensure the correct blood product is given.

C. Infusing the unit of blood within 4 hours is essential to reduce the risk of bacterial growth in the blood product.

D. Obtaining baseline vital signs prior to starting the transfusion is important to assess the client's condition and monitor for any changes during the transfusion.

E. Continuously monitoring the client during the first 15 minutes of the transfusion is vital for detecting any signs of a transfusion reaction promptly.

F. Inserting an 18-gauge intravenous catheter is recommended for blood transfusions as it provides a sufficient lumen to accommodate the blood flow.

G. Inserting a 22-gauge intravenous catheter is acceptable for some transfusions, but an 18-gauge is preferred for larger blood products.

A. Candidiasis B. Xerostomia C. Halitosis D. Gingivitis

Correct Answer is A

Explanation

A. Candidiasis, commonly known as thrush, is characterized by white lesions on the tongue and is a common opportunistic infection in clients with AIDS due to their compromised immune system.

B. Xerostomia refers to dry mouth and does not cause white lesions; it can occur in various conditions but is not an opportunistic infection.

C. Halitosis is bad breath and does not correlate with white lesions on the tongue; it can result from various causes but is not an infection.

D. Gingivitis involves inflammation of the gums and may present with red, swollen gums but does not typically cause white lesions on the tongue.

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A nurse is monitoring a client receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?

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Naxlex Comprehensive Predictor Exams

Which nursing interventions are appropriate for a nurse administering a blood transfusion? Select All That Apply

Correct Answer is ["B","C","D","E","F"]

Explanation

A nurse is caring for a client with acquired immunodeficiency syndrome (AIDS). The nurse notes white lesions on the client's tongue. What opportunistic infection is this client experiencing?

Correct Answer is A

Explanation

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