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 ["A","E","F"]

Explanation

A. Ensure comfortable seating at eye level for the client and nurse: Establishes a non-intimidating environment, helping the client feel more at ease.

B. Provide seating for the client so that the client faces a strong light: Incorrect; this may cause discomfort and make the client feel scrutinized.

C. Ensure that the distance between the client and nurse is at least 7 ft: Too great a distance for effective communication; ideal distance is 3-4 feet.

D. Place a chair for the client across from the nurse's desk: Creates a formal, potentially intimidating setting, discouraging openness.

E. Set the room temperature at a comfortable level: Ensures physical comfort, aiding in client relaxation and openness.

F. Remove distracting objects from the interviewing area: Minimizes potential distractions, keeping the client focused and the environment conducive to communication.

A. "Decrease intake of foods high in fiber as this medication may cause loose stools." B. "Avoid consuming high in vitamin C within one hour of taking the medication." C. "Stools may become darker in color while taking this medication." D. "Take the medication on a full stomach for better absorption."

Correct Answer is C

Explanation

A. Decreasing intake of foods high in fiber is not necessary; in fact, fiber can help prevent constipation, a common side effect of iron supplements.

B. Vitamin C actually enhances the absorption of iron; thus, avoiding it is incorrect. Clients should be encouraged to consume vitamin C alongside their iron supplements to improve absorption.

C. Stools becoming darker in color is a common and expected side effect of ferrous sulfate due to the presence of unabsorbed iron. It is important for clients to know this to avoid unnecessary alarm.

D. Taking the medication on a full stomach may decrease absorption; it is generally recommended to take iron supplements on an empty stomach for optimal absorption unless gastrointestinal upset occurs.

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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

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